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EDINBURGH 

"I 


MEDICAL    JOURNAL, 


COHBININQ 

THE  MONTHLY  JOURNAL  OF  MEDICINE 

AM) 

THE  EDINBURGH  MEDICAL  AND  SURGICAL  JOURNAL. 

VOL.  XXXIV.— PART  II. 

JANUARY    TO     JUNE    1889. 


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o 


EDINBURGH:  ^^ 

OLIVER   AND    BOYD,    TWEEDDALE    COURT. 
LONDON:  SIMPKIN,  MARSHALL,  AND  CO. 


MDCCCLXXXIX. 


EniNBURan:   printed  bf  Oliver  and  bo?d,  tweeddale  court. 


|3att  jriv0t. 

ORIGINAL    COMMUNICATIONS. 

I.— AN  EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 
STOKES  RESPIRATION. 

By  G.  A.  Gibson,  M.D. 

Few  symptoms  have  within  an  equally  brief  space  of  time 
excited  so  much  discussion  as  that  peculiar  modification  of  the 
respiratory  rhythm  which  in  every  language  bears  the  names  of 
Cheyne  and  Stokes,  and,  as  so  much  has  already  been  written  on  the 
subject,  there  cannot  fail  to  be  some  hesitation  before  adding 
another  to  the  many  contributions  towards  its  elucidation.  In  our 
own  country,  however,  the  symptoms  which  frequently  accompany 
the  type  of  breathing  in  question  are  but  imperfectly  known, 
while  of  the  many  explanations  that  have  been  advanced  to  account 
for  its  appearance,  very  few  have  been  seriously  considered,  and  it 
therefore  seems  unnecessary  to  give  any  reasons  for  bringing  the 
matter  forward  once  more.  During  the  last  four  years  several 
excellent  examples  of  this  type  of  breatliing  have  been  under  my 
observation,  and  these  have  led  me  to  study  the  phenomena  which 
are  linked  with  it,  as  well  as  to  criticise  the  theories  that  have 
been  formed  to  explain  its  mode  of  origin.  In  the  following  pages 
the  results  of  these  investigations  are  fully  embodied,  and  as  they 
naturally  fall  into  three  classes,  it  will  be  of  advantage  to  group 
them  in  three  divisions :  historical,  clinical,  and  critical. 

Historical. 

The  type  of  breathing  which  forms  the  subject  of  the  present 
remarks  has  aroused  a  great  amount  of  interest  and  produced 
a  corresponding  number  of  contributions  to  medical  science. 
Occurring  as  it  does,  moreover,  in  the  course  of  very  various  affec- 
tions, the  symptom  is,  as  might  be  expected,  referred  to  in  works 
on  many  different  diseases.  The  literature  of  the  subject  has 
therefore  assumed  large  proportions.  Many  of  the  writings  which 
have  been  devoted  to  it  are  of  but  little  value,  and  yet  they  have 
served  a  useful  purpose  by  throwing  light  upon  some  of  its  phases, 
or  by  recording  its  presence  in  conditions  where  it  had  not  been 
observed  before.     Others  again  are  remarkable  at  once  for  their 

EDIXBURGH    MED.    JOURN.,    VOL.    XXXIV. — XO.    VII.  4   E 


586  DR   G.   A.    GIBSON   ON   THE  [jAN. 

clinical  acumen  and  critical  insight.  Many  even  of  the  most 
important  are  utterly  unknown  to  the  literature  of  this  country, 
and  it  seems  to  be  my  duty,  even  at  the  risk  of  being  here  and  there 
somewhat  tedious,  to  mention,  to  an  extent  proportionate  to  their 
value,  the  different  writings  on  the  subject. 

Hippocrates,  like  many  other  writers  of  antiquity,  has  suffered  at 
the  hands  of  his  admirers,  and  his  works  have  so  often  been  wrested 
to  suit  the  individual  views  of  subsequent  authors,  that  his  name 
is  only  mentioned  here  with  a  certain  degree  of  reluctance.  It 
seems  almost  beyond  doubt,  however,  that  in  the  First  Book  of 
the  Epidemics  he  makes  reference  eitlicr  to  the  type  of  breathing 
about  to  be  considered  or  to  some  nearly  allied  form  of  respiration. 
In  describing  the  case  of  Philiscus,  who  died  of  an  acute  disease 
of  a  somewhat  indefinite  kind,  accompanied  by  an  enlargement  of 
the  spleen,  he  remarks^: — "  Tovrew  Tri/eviua  Sia  reXeo?,  cocnre? 
avaKoXovimeuw  apaiov,  jmeya.  In  this  case,  the  respiration  until  the 
end,  like  that  of  some  one  recollecting  himself,  was  infrequent  and 
deep;"  or,  as  it  has  been  rendered  by  Adams,^  "The  respiration 
througliout,  like  that  of  a  person  recollecting  himself,  was  rare  and 
large."  The  last-named  author  remarks  in  a  footnote, — "  The 
modern  reader  will  be  struck  with  the  description  of  the  respira- 
tion, namely,  that  the  patient  seemed  like  a  person  who  forgot  for 
a  time  the  besoin  de  respirer,  and  then,  as  it  were,  suddenly 
recollected  himself.  Such  is  the  meaning  of  the  expression  as 
explained  by  Galen  in  his  Commentary,  and  in  his  work  On 
Difficulty  of  Breathing." 

In  his  learned  address  on  Medicine,  delivered  before  the  Edin- 
burgh meeting  of  the  British  Medical  Association,  Warburton 
Begbie^  called  attention  to  this  observation  of  Hippocrates,  and 
the  matter  is  put  so  clearly  that  it  will  be  well  to  quote  his 
words : — "  It  is,  however,  in  respect  to  tlie  peculiar  character  of  the 
breathing  that  the  case  of  Pliiliscus  acquires  its  chief  interest, 
and  it  is  in  this  particular  that  a  resemblance  is  to  be  found 
between  the  ancient  and  the  modern  examples  now  quoted.  The 
attention  of  Hippocrates  had  been  arrested  by  the  peculiar  char- 
acter of  the  breathing  which  existed  throughout  the  fatal  illness  of 
Philiscus.  Surely  it  is  matter  of  interest  and  for  reflection  that 
the  respiration  described  by  Hippocrates  as  apaiou  /neya,  'rare 
and  large,'  and  to  which  Galen  has  attached  the  meaning,  '  like  a 
person  who  forgot  for  a  time  the  need  of  breathing,  and  then 
suddenly  remembered,'  or  'the  respiration  throughout,  like  that 
of  a  person  recollecting  himself,  was  rare  and  large,'  has  attracted 
great  attention  in  quite  recent  times.  The  expression  used  by 
French  writers,  *  besoin  de  respirer,'  corresponds  in  some  measure 
to  the  meaning  which  is  sought  to  be  conveyed  by  the  Greek 

1  (Euvres  completes  d'Eippocrate,  par  E.  Littre,  tome  ii.  p.  684.     Paris,  1840. 

2  The  Genuine  Works  of  Hippocrates,  vol.  i.  p.  371.     London,  1849. 

3  British  Medial  Journal,  vol.  ii.  for  1875,  p.  164. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  587 

words.  In  Latin  the  rendering  is, '  Spiratio  huic  perpetuo  rara  et 
magna  fuit.'  Daremberg,  the  learned  French  editor  of  Hippo- 
crates, thus  translates  the  passage :  '  La  respiration  fiit  constam- 
ment  grande,  rare  comme  chez  quelqu'un  qui  ne  respire  que  par 
souvenir.' " 

With  the  exception  of  this  observation  made  by  the  Father  of 
Medicine,  the  peculiar  form  of  breathing  which  we  are  about  to 
consider  remained  unnoticed  until  Cheyne,  who  carried  the  torch  of 
medical  science  from  our  own  shores  to  those  of  the  sister  island, 
observed  it  anew.  In  reporting'  a  case  of  fatty  degeneration  of 
the  heart,  he  thus  describes  the  type  of  the  respiration : — "  The 
only  peculiarity  in  the  last  period  of  his  illness,  which  lasted  only 
eight  or  nine  days,  was  in  the  state  of  the  respiration.  For 
several  days  his  breathing  was  irregular ;  it  would  entirely  cease 
for  a  quarter  of  a  minute,  then  it  would  become  perceptible, 
though  very  low,  then  by  degrees  it  became  heaving  and  quick,  and 
then  it  would  gradually  cease  again :  this  revolution  in  the  state 
of  his  breathing  occupied  about  a  minute,  during  which  there 
were  about  thirty  acts  of  respiration."  In  the  description  of  the 
dissection,  it  is  noted  that  there  were  between  three  and  four 
ounces  of  fluid  in  the  ventricles  of  the  brain.  A  very  interesting 
observation,  which  has  most  frequently  escaped  the  notice  of 
subsequent  writers,  is  contained  in  a  footnote,  where  Ciieyne 
remaiks:^ — "The  same  description  of  breathing  was  observed  by 
me  in  a  relative  of  the  subject  of  this  case,  who  also  died  of  a 
disease  of  the  heart,  the  exact  nature  of  which,  however,  I  am 
ignorant  of,  not  having  been  permitted  to  examine  the  body  after 
death." 

Berton^  mentions  changes  in  respiratory  rhythm  as  being  a 
common  symptom  in  cerebral  inflammations,  and  quotes  some 
remarks  by  Dance,  in  which  breathing,  not  very  unlike  that 
under  consideration,  is  described.  Subsequent  French  writers  on 
children's  diseases  follow  in  the  same  path. 

It  has  been  stated  that  Flourens,  in  the  course  of  his  celebrated 
experiments,  observed  the  occurrence  of  periodic  breathing  as  the 
result  of  injury  to  the  nerve  centres.  But  in  the  first  edition  of 
his  work^  there  is  no  reference  to  such  a  phenomenon,  while  in 
the  second  edition  the  exact  condition  which  is  mentioned  admits 
of  considerable  doubt.  In  the  second  edition,  when  criticising  the 
observations  of  Marshall  Hall,  and  describing  the  results  of  some 
experiments  on  the  medulla  oblongata,^  he  says: — "Je  r(5petai 
cette  experience,  sur  un  lapin.     L' animal  surv^cut  h.  Toperation 

1  Dublin  Hospital  Reports,  vol.  ii.  p.  216,  1818. 

2  Ihid.,  p.  222. 

3  Traite  des  Maladies  des  Enfants,  p.  67.     Paris,  1837. 

*  Recherches   Exp^rimentales  sur  les  Proprid/s  et  les  Fondions  du  Systevie 
Nerveux,  dans  les  Animaux  Vertibi-es,  p.  168  et  seq.     Paris   1824. 
"  Ibid.,  Deuxieme  edition,  p.  206,  1842. 


588  I)K    G.    A.    GIBSON    ON    THE  [jAN. 

pendant  a  pen  pr^s  vingt-deux  minutes :  sa  respiration  n'etait 
plus,  k  la  v^rite,  continue ;  mais  elle  se  reproduisait  de  temps  en 
temps,  et  surtout  quand  on  irritait  Tanimal."  Such  arrests  of  the 
respiration,  as  will  be  seen  later,  are  regarded  by  some  authors  as 
belonging  to  the  same  series  as  Cheyne-Stolves  respiration ;  they 
are  looked  upon  as  essentially  different  by  others. 

West^  briefly  refers  to  irregularity  of  breathing  as  frequently 
occurring  in  inflammations  of  the  brain  and  meninges,  and  later 
authors  in  this  country  also  do  so, 

Stokes,  whose  name,  as  well  as  Cheyne's,  is  now  indissolubly 
bound  up  with  the  peculiarity  of  breathing  in  question,  made  it 
pathognomonic  of  fatty  degeneration  of  the  heart.  Speaking  of 
the  symptoms  of  this  condition  he  says:^ — "  But  there  is  a  symptom 
which  appears  to  belong  to  a  weakened  state  of  the  heart,  and 
which,  therefore,  may  be  looked  for  in  many  cases  of  the  fatty 
degeneration.  I  have  never  seen  it  except  in  examples  of  that 
disease.  The  symptom  in  question  was  observed  by  Dr  Cheyne, 
although  he  did  not  connect  it  with  the  special  lesion  of  the  heart. 
It  consists  in  the  occurrence  of  a  series  of  inspirations,  increasing 
to  a  maximum,  and  then  declining  in  force  and  length,  until  a  state 
of  apparent  apncea  is  established.  In  this  condition  the  patient 
may  remain  for  such  a  length  of  time  as  to  make  his  attendants 
believe  that  he  is  dead,  when  a  low  inspiration,  followed  by  one 
more  decided,  marks  the  commencement  of  a  new  ascending  and  then 
descending  series  of  inspirations.  This  symptom,  as  occurring  in 
its  highest  degree,  I  have  only  seen  during  a  few  weeks  previous 
to  the  death  of  the  patient,  I  do  not  know  any  more  characteristic 
phenomena  than  those  presented  in  this  condition,  whether  we 
view  the  long  continued  cessation  of  breathing,  yet  without  any 
suffering  on  the  part  of  the  patient,  or  the  maximum  point  of  the 
series  of  inspirations,  when  the  head  is  thrown  back,  the  shoulders 
raised,  and  every  muscle  of  inspiration  thrown  into  the  most 
violent  action ;  yet  all  this  without  rale  or  any  sign  of  mechanical 
obstruction.  The  vesicular  murmur  becomes  gradually  louder,  and 
at  the  height  of  the  paroxysm  is  intensely  puerile. 

"  The  decline  in  the  length  and  force  of  the  respirations  is  as 
regular  and  remarkable  as  their  progressive  increase.  The  inspira- 
tions become  each  one  less  deep  than  the  preceding,  until  they  are 
all  but  imperceptible,  and  then  the  state  of  apparent  apnoea  occurs. 
This  is  at  last  broken  by  the  faintest  possible  inspiration  ;  the  next 
effort  is  a  little  stronger,  until,  so  to  speak,  the  paroxysm  of  breath- 
ing is  at  its  height,  again  to  subside  by  a  descending  scale." 

Hasse,^  writing  a  year  later  than  Stokes,  observes,  in  describing 
the  symptoms  of  tubercular  meningitis,  that  "  long  pauses  occur 

^  Lectures  on  the  Diseases  of  Infancy  and  Childhood,  p.  16.     London,  1848. 
'  The  Diseases  of  the  Heart  and  of  the  Aorta,  p.  324.     Dublin,  1854, 
3  Handhuch    der   speciellen    Pathologie   und   Therapie,   redigirt  von   Eudolf 
Virchow,  iv.  Band,  i.  Abtheilung,  S.  473.     Erlangen,  1855. 


1889.]  PIIEXOMEKA    IN    CHEYNE-STOKES    IIESPIKATION.  589 

now  and  then,  as  if  the  patients  had  for  tlie  time  forgotten  inspira- 
tion." This  may,  however,  have  been  an  allied  type  of  intermittent 
respiration. 

Schweig,^  writing  in  ignorance  of  previous  observations,  brings 
forward  periodic  breathing  as  a  new  symptom,  and  it  is  clear  from 
his  remarks  that  he  had  the  true  plienomenon  of  Cheyne  and  Stokes 
before  him.     He  records  several  cases.     In  all  there  was  a  comatose 
tendency  preceding  or  accompanying  the  onset  of  the  symptom 
in  question.     After  death,   one    was   found  to   have    thickening 
of  the  skull,  several  ounces  of  fluid  in  the  left  ventricle,  a  flabby, 
but    otherwise    healthy,   heart,   old    tubercular    masses    in    the 
pulmonary  apices,  and  abdominal  adhesions.     No  notice  is  taken 
of  the  state  of  the  kidneys.     The  second,  in  which  the  author 
states  there  was  no  change  in  the  pulse  during  the  phases  of  the 
breathing,  had  thickening  of  the  skull,  dropsy  of  the  ventricles,  old 
tubercular  lesions  in  the  lungs,  and  atheroma  with  cardiac  hyper- 
trophy.    The  state  of  the  kidneys  is  not  mentioned.     The  tliird 
was  a  case  of  renal  disease  with  hypertrophy  of  the  heart,  dropsy 
of  the  pleurse,  and  oedema  of  tlie  legs.     Here  again  it  is  noted  tliat 
neither  phase  of  the  respiration  had  any  influence  on  the  pulse. 
The  head  was  not  examined  after  death.     In  the  fourth  case  there 
was  atheroma  of  the  vessels  with  fatty  degeneration  of  the  heart, 
thickening  of  the  skull,  and  a  considerable  quantity  of  fluid  in  the 
left  ventricle  of  the  brain.     The  kidneys  receive  no  notice.     He 
lays  stress  in  all  these  cases  on  the  comatose  tendency,  and  in  the 
three  whose  heads  were  examined  on  the  sclerosis  of  the  skull,  and 
the  chronic  hydrocephalus,  but  especially  emphasizes  the  fact  that 
on  the  left  side  in  these  three  cases  the  foramen  jugulare  was 
greatly  narrowed,  and  thus  caused  pressure   on  the  vagus  and 
accessorius  nerves.     After  these  remarks  he  describes  another  case 
in  which,  after  various  affections  especially  connected  with  the 
brain,  pneumonia  ensued,  and  was  followed,  after  severe  mental 
troubles,  by  periodic  respiration  with  gradual  development  of  coma. 
The  author  diagnosed  thickening  of  the  skull,  narrowing  of  the  left 
cranial  cavity,  left-sided  hydrocephalus,  and  stenosis  of  the  left  fora- 
men lacerum.    The  necropsy  revealed  thickening  of  the  skull  with 
osseous  deposits,  oedema  of  the  pia  mater,  bleeding  points  throughout 
the  brain  substance,  distention  of  the  left  ventricle  by  fluid  and  some 
also  of  the  right,  atheroma  of  the  basilar-artery,  and  great  stenosis  of 
the  left  jugular  foramen,  which  was  only  one-third  of  the  size  of  the 
opposite  one.     The  heart  was  adherent  to  the  pericardium  and 
enormously  hypertrophied,  with  atheroma  of  the  mitral  and  aortic 
valves,  great  dilatation  of  the  right  side  of  the  heart,  a  considerable 
amount  of  fluid  in  the  pleurse,  which  were  adherent  in  great  part, 
and  tubercular  lesions  in  the  lungs.     Tlie  kidneys  escape  observa- 
tion.    A  sixth  case  is  mentioned,  still  alive  when  the  paper  was 

^  Aerztliche  Mittheilungen  aus  Baden,  xi.  Jahr{:;ang,  S.  49,  1857. 


590  DR   G.    A.    GIBSON   ON   THE  [jAN. 

published,  in  which  cardiac  disease  was  followed  by  mental 
affections  accompanied  by  periodic  breathing. 

Soon  afterwards  similar  phenomena  were  produced  experi- 
mentally, for  we  find  that  Schiff^  observed  the  characteristic 
breathing  as  the  result  of  haemorrhages  involving  the  medulla 
oblongata,  but  not  directly  affecting  the  vital  spot.  He  says  :• — 
"  Injury  of  other  parts  of  the  medulla  oblongata  than  that 
described  above  permit  indeed  life  and  breathing  to  go  on,  but 
probably  through  the  accompanying  haemorrhage,  which  influences 
the  respiratory  centre,  it  may  modify  the  respiration  in  two  ways. 

"  a.  Every  sliglit  hoemorrhage  upon  the  medulla  oblongata,  and 
every  pressure  upon  it,  makes  the  breathing  less  frequent  and  more 
laboured. 

"  h.  If  the  haemorrhage  be  larger  or  the  pressure  greater,  a 
peculiar  symptom  is  observed  in  different  mammals,  the  like  of 
which  I  have  as  yet  sought  in  vain  for  in  human  pathology,  and  to 
which  I  may  direct  the  attention  of  physicians.  The  respirations 
entirely  cease  for  a  quarter  of  a  minute  or  half  a  minute,  then  begin 
gradually,  increase  their  rate,  and  afterwards  wane,  until  a  new 
pause  occurs.  This  appears  to  be  caused  by  variations  in  the 
amount  of  the  pressure,  which  is  of  necessity  dependent  on  the 
power  of  the  heart  beat."  From  this  it  is  evident  that  Schiffs 
attention  had  never  been  called  to  the  observations  of  Cheyne, 
Stokes,  or  Schweig. 

Eeid,^  in  reporting  two  cases  of  aneurism  with  this  symptom,  one 
of  a  man  aged  60,  the  other  that  of  a  woman  aged  59,  notes  that  the 
pulse  was  periodically  irregular,  becoming  less  frequent  during  the 
respiratory  distress,  and  more  so  when  the  distress  was  lessened. 

In  another  paper^  the  same  author  describes  a  case  of  aortic  and 
mitral  disease,  without  any  change  in  the  texture  of  the  muscular 
walls  on  dissection,  and  from  a  study  of  it  he  concludes  "  that  the 
symptoms  of  respiratory  distress  must  henceforth  cease  to  be  looked 
upon  by  me  as  pathognomonic  of  fatty  degeneration  of  that  organ." 
He  observes  that  in  this  patient  "  the  pulse  becariie  invariably  slow 
when  the  distress  was  greatest,  and  as  invariably  quick  when  it  was 
subsiding,  or  whilst  the  patient  had  ceased  to  breathe."  He  is  inclined 
to  think  that  this  change  in  the  pulse  is  not  a  mere  coincidence, 
"  but  that  it  and  the  distress  stand  towards  each  other  in  the 
relation  of  cause  and  effect ; "  he  does  not,  however,  venture  upon 
any  theory. 

Trousseau^  mentions,  as  characteristic  of  cerebral  inflammations, 
a  symptom,  which,  if  not  exactly  the  same  as  Cheyne-Stokes 
respiration,  has  a  great  resemblance  to  some  forms  of  that  type  of 

^  Cyclus  organisch  verhundener  Lehrbiicher  sdmmtlicher  medicinischen  Wissen- 
schaften,  herausgegeben  von  Dr  C.  H.  Schauenburg,  ix.  Theil,  i.  Band,  S.  324. 
Lohr,  1858-59. 

2  The  Dublin  Hospital  Gazette,  vol.  vi.  p.  308,  1859. 

3  Ibid.,  vol.  vii.  p.  133,  1860. 

*  Clinique  ATedicale  de  I'Hotel-Dieu  de  Paris,  tome  ii.  p.  318.     Pans,  1862. 


1889.]  PHENOMENA   IN   CHEYNE-ST0KE3   RESPIKATION.  591 

breathing,  as  it  has  not  only  the  cessation  of  respiration,  but  also 
the  ascending  and  descending  phases. 

Eeferring  to  this  subject  in  the  third  edition  of  his  treatise, 
Walshe'  remarks : — "  I  cannot  avoid  inferring  that  the  proximate 
cause  lies  in  a  failure  of  the  special  nervous  excitant  of  the 
respiratory  act — in  ana3Sthesia  either  of  the  vagus  or  of  the  medulla 
oblongata  itself."  This  opinion  is  simply  adhered  to  in  the  last 
edition  of  the  work.^ 

In  a  lecture  by  Laycock,  reported  by  Ropes,^  there  is  a  descrip- 
tion of  the  peculiar  breathing,  and  it  is  stated  that  the  most 
probable  explanation  of  the  phenomena  "  is  that  a  sentient  palsy 
of  the  respiratory  centre  occurs,  or  a  paresis  of  reflex  sensibility  of 
the  mucous  membrane  of  the  lung." 

hi  a  research  undertaken  with  a  view  to  solve  some  physio- 
logical and  pathological  questions  connected  with  the  brain, 
Leyden*  notes  that  when  the  pressure  is  abnormally  raised  in 
animals  there  are  changes  in  the  respiration,^  The  breathing 
became  irregular,  long  pauses  separating  periods,  during  which 
respirations  rapidly  succeeded  eacii  other,  so  that,  as  the  author 
states,  there  was  a  similarity  to  Cheyne-Stokes  respiration ;  there 
was  never  such  a  regular  periodicity  of  the  events  or  transition  from 
the  breathing  to  the  pause.  It  is  of  interest  to  observe  that  in 
this  contribution,  in  addition  to  changes  of  sensibility,  mobility, 
and  intelligence,  the  author  noted'  alterations  in  the  pupils. 

Head '^  recorded  a  case  which  presented  this  symptom,  and  in 
which  fatty  degeneration  of  the  diaphragm  was  found  after  death, 
with  atheromatous  degeneration  and  dilatation  of  the  aorta,  and 
aortic  incompetence.  In  this  paper  is  a  full  notice  of  the  condition 
of  the  pulse  during  the  two  stages  of  apnoea  and  dyspnoea ;  from 
tracings  taken  by  Grimshaw  it  was  observed  that  the  pulse  was 
as  strong  during  the  former  as  the  latter  phase,  wdiile  tracings 
obtained  from  another  case  under  the  care  of  Little  showed 
stronger  pulsations  during  the  cessation  of  respiration. 

This  type  of  respiration  is  said  by  von  Dusch**  to  occur  in 
affections  of  the  brain,  and  in  uraemic  coma,  and  he  also  states  that 
he  has  observed  it  in  one  severe  case  of  pericarditis. 

Little^  published  a  few  cases  in  which  the  symptom  was 
prominent,  one  being  an  example  of  fatty  degeneration  of  the 
heart,  another   of   aortic   stenosis   and   hypertrophy  of  the   left 

^  A  Practical  Treatise  on  the  Diseases  of  the  Heart  and  Great  Vessels.  Third 
edition,  p.  345.    London,  1862. 

2  Ibid.     Fourth  edition,  p.  407.     London,  1873. 

3  The  Medical  Journal  for  1864,  p.  116. 

*  Archiv  fiir  pathologische   Anatomie   und   Physiologie  und  fiir  Klinische 
Medicin,  xxxvii.  Band,  S.  519,  1866. 
6  Op.  cit.,  S.  553  und  S.  554. 
6  Op.  cit,  S.  549  und  S.  550. 
'^  Dublin  Quarterly  Journal  of  Medical  Science,  vol.  xliv.  p.  405,  1867. 

8  Lehrbuch  der  Herzkrankheiten,  S.  153.      Leipzig,  1868. 

9  Dublin  Quarterly  Journal  of  Medical  Science,  vol.  xlvi.  p.  46,  1868. 


592  DR   G.    A.   GIBSON   ON   THE  [jAN. 

ventricle,  and  a  third  of  renal  disease  with  atheromatous  degenera- 
tion and  dilatation  of  the  aorta,  and  thickening  of  the  aortic  valves. 
The  author  of  this  contribution  ingeniously  argues  that  the  cause 
of  the  peculiar  respiration  is  a  loss  of  balance  between  the  two 
sides  of  the  heart,  either  tlirough  diminished  force  of  the  left 
ventricle,  as  in  fatty  degeneration,  or  when  some  abnormal  burden 
has  been  imposed  on  the  left  ventricle,  under  whicli  it  is  unable 
to  get  rid  of  blood  as  quickly  as  it  is  supplied  to  it,  and  the  blood 
accumulates  in  the  left  auricle  and  the  pulmonary  veins  and 
capillaries.  Being  fully  oxygenated,  this  blood  fails  to  excite  the 
terminal  filaments  of  the  vagus,  as  venous  blood  does,  and  the 
respiration  ceases.  A  few  pulsations  then  displace  this  blood,  and 
the  venous  blood  streaming  in  excites  the  respiration  anew.  He 
also  states  his  belief  that  the  altered  rhythm  of  the  respiration  is 
only  found  when  the  lesion  which  has  destroyed  the  balance 
between  the  two  ventricles  has  been  rapidly  produced ;  that  when 
this  is  not  the  case  the  ventricles  adapt  themselves  to  the  changed 
conditions. 

Benson^  describes  a  case  of  mitral  disease  in  which  cerebral 
haemorrhage  occurred  followed  by  the  type  of  respiration  which  we 
are  considering,  and  he  gives  expression  to  his  opinion  that  the 
theory  propounded  by  Little  is  a  "  true  account  of  the  essential 
mechanism  of  the  phenomenon,"  but  adds  that  he  thinks  "  a  certain 
nervous  complication  is  necessary  to  determine  the  accession  of 
this  peculiar  form  of  respiration,  and  without  which  it  would  not 
occur."  He  also  notes,  in  the  description  of  his  case,  that  it  was 
only  while  the  patient  was  allowed  to  remain  in  the  semi-comatose 
state  that  the  peculiar  respiratory  rhythm  showed  itself;  when 
roused  up,  the  respiration  became  almost  normal,  and  assumed  the 
ascending  and  descending  character  when  the  condition  of  stupor 
was  permitted  to  return.  He  distinctly  states  liis  belief  that  the 
nervous  centres  were  incapacitated  for  work  by  the  cerebral  lesion ; 
that  this  produced  arrest  of  the  respiration,  that  the  centres  after 
a  certain  time  regained  their  excitability  sufficiently  to  reflect  a 
motor  impulse,  thus  re-establishing  respiration,  but  that  being 
weak,  the  centres  could  not  sustain  the  effort  and  apnoea  again 
occurred,  and  so  on.  He  therefore  concludes  that  there  must  in 
every  case  be  a  diseased  condition  of  the  circulatory  and  of  the 
nervous  mechanism,  a  double  pathological  condition,  which  he 
states  as  follows  : — 

"  1.  A  certain  diseased  state  of  the  heart,  by  reason  of  which, 
indirectly,  the  excito-motor  impulse  upon  the  nervous  centres, 
conveyed  through  the  pulmonary  branches  of  the  pneumogastric,  is 
diminished. 

"  2.  A  certain  weakened  state  of  those  nervous  centres,  by  reason 
of  which  the  reflecto-motor  impulse  is  diminished," 

1  Dublin  Quarterly  Journal  of  Medical  Science,  vol.  xlviii.  p.  12V,  1869. 


1889.]  PHENOMENA   IN    CHEYNE-STOKES   RESPIRATION.  593 

This  brings  us  to  the  period  of  the  classical  clinique,  in  which 
Traube  expounded  his  theory,  published  by  Frautzel/  and  re- 
printed in  his  collected  works.^  Describing  a  ca.se  of  aortic  and 
mitral  disease,  with  hypertrophy  of  the  left  and  dilatation  of  the 
right  ventricle,  in  which  the  phenomenon  appeared  after  a  sub- 
cutaneous dose  of  morphine,  he  takes  the  opportunity  to  mention 
the  first  case  in  which  he  had  met  with  this  symptom — one  of 
cerebral  haemorrhage — and  refers  to  other  instances  of  cerebral 
hemorrhage,  as  well  as  cerebral  tumours,  tubercular  meningitis, 
and  ursemic  coma,  which  presented  it.  He  concludes,  therefore, 
that  the  peculiar  type  of  respiration  may  occur  in  two  classes  of 
patients :  1.  Those  with  healthy  hearts,  but  diseased  contents  of 
the  cranial  cavity ;  2.  Those  with  healthy  contents  of  the  cranial 
cavity,  but  diseased  hearts.  He  further  observes  that  the  duration 
of  the  periods  may  be  so  short,  and  the  pauses  so  inappreciable, 
that  the  phenomenon  may  escape  notice ;  that,  towards  the  end  of 
long  pauses,  muscular  twitchings  may  occur  closely  resembling 
those  seen  when  the  artificial  respiration  is  suspended  in  slightly 
curarised  animals ;  and  that  sometimes  during  long  pauses  the 
tension  of  the  arteries  rises,  while  the  pulse-rate  diminishes. 
He  proceeds  to  point  out  that  all  the  cases  in  which  the  pheno- 
menon is  present  have  one  characteristic — they  have  all  a  diminu- 
tion of  the  supply  of  arterialized  blood  to  the  medulla,  where  the 
respiratory  centre  is  situated.  There  is  thus  a  smaller  supi)ly  of 
oxygen,  of  which  we  know  that  it,  in  a  higher  degree,  influences 
the  irritability  of  the  cellular  nervous  elements.  Through  this 
lessened  amount  of  oxygen  the  irritability  of  the  nerve  cells 
l)ecomes  so  much  lowered  that  a  larger  quantity  of  carbonic  acid 
is  required  to  cause  an  inspiration,  and  therefore  the  time  within 
which  the  carbonic  acid  will  accumulate  in  sufficient  quantity  is 
lengthened.  This  is  similar  to  the  effects  of  section  of  the  vagi, 
in  which  long  pauses  occur  in  the  respiration,  attended  by  dyspnoea. 
The  respiration  may  be  excited  in  two  ways  :  1.  By  the  pulmonary 
fibres  of  the  vagus,  whose  peripheral  terminations  are  probably 
washed  by  the  blood,  and  whose  central  ends  are  connected  with 
the  respiratory  centre ;  and  2.  By  the  aff'erent  nerves  coming  from 
all  parts  of  the  body,  which  are  able  to  send  a  sufficient  stimulus 
to  the  medulla,  as  in  the  case  of  dashing  cold  water  on  the  skin, 
and  the  well-known  effect  of  the  gastric  portion  of  the  vagus  on 
the  respiration.  The  diff'erence  between  these  two  is  this,  that  the 
pulmonary  endings  of  the  vagi  are  bathed  in  blood  containing 
much  carbonic  acid,  while  the  others  have  a  supply  of  blood  which 
contains  but  little.  If  both  be  equally  irritable,  then  in  health 
only  the  pulmonic  vagi  will  be  called  into  action.  If  the  vagi  be 
cut  the  respiratory  centre  can  only  be  excited  by  the  other  nerves, 

^  Berliner  klinische  JVochenscJirift,  vi.  Jahrgang,  S.  277,  1869. 
2  Gesammelte  Beitraye  zur  Fathologie  und  Physiologie,  ii.  Band,  S.  882.    Berlin, 
1871. 

EDINBURGH   MED.    JOURN.,    VOL,    XXXIV. — NO.   VII.  4  F 


594  DR   G.   A.   GIBSON   ON   THE  [jAN. 

and  this  can  only  happen  when  the  blood  circulating  throughout  the 
body  is  as  rich  in  carbonic  acid  as  that  normally  passing  into  the 
lungs.  It  must  be  borne  in  mind  that  tlie  number  of  the  vagus 
fibres  is  incomparably  smaller  than  that  of  the  other  nerves ;  when 
these  latter  act,  therefore,  the  effect  is  correspondingly  greater,  and 
simple  respiration  becomes  dyspnoea.  Applying  this  reasoning  to 
the  phenomenon  in  question,  we  find  that  the  lessened  irritability 
of  the  respiratory  centre,  caused  by  the  cerebral  pressure,  or 
uroemic  blood,  or  deficient  arterial  supply,  requires  a  larger  amount 
of  carbonic  acid  as  a  stimulus,  and  thus  there  is  a  long  pause. 
When  this  gas  has  accumulated  in  sufficient  quantity  it  first 
stimulates  the  pulmonary  terminations  of  the  vagi,  but,  as  was 
shown  long  before  by  Traube,  the  strongest  stimuli  applied  to  the 
vagi  never  cause  dyspnoea,  and  this  only  causes  the  shallow  breathing 
which  appears  first  after  the  pause.  The  amount  of  carbonic  acid 
meantime  increases  sufficiently  to  cause  stimulation  of  the  nerves 
coming  from  the  skin  and  other  parts  of  the  body,  and  hence  the 
dyspnoea  sets  in.  The  quantity  of  the  gas  is  greatly  diminished 
by  the  forcible  breathing,  and  the  excitement  of  the  other  nerves 
ceases,  so  with  the  action  of  the  vagi  alone  shallow  breathing  again 
occurs,  until  there  is  not  enough  carbonic  acid  gas  to  excite 
the  pulmonary  endings  of  the  vagi,  and  a  pause  sets  in  anew, 
Traube  ends  by  calling  attention  to  the  fact  that  the  morphine 
directly  induced  the  peculiar  respiratory  rhythm  by  reducing  the 
irritability  of  the  respiratory  centre  in  a  case  where  it  was  already 
at  a  low  ebb. 

Mader^  describes  five  cases  in  which  Cheyne-Stokes  respiration 
was  present ;  an  extravasation  into  the  floor  of  the  fourth  ventricle  ; 
a  tumour  between  the  medulla,  pons,  and  cerebellum  ;  an  extra- 
vasation reaching  from  the  right  optic  thalamus  to  the  medulla ; 
an  enlargement  of  the  vertebral  artery  compressing  the  medulla ; 
and,  lastly,  renal  disease  with  a  tumour  of  the  pons.  He  main- 
tains that  the  cause  of  the  phenomenon  must  be  sought  in 
anatomical  changes  in  the  medulla  oblongata,  and  opposes  the 
view  of  Traube  that  the  respiratory  change  can  take  place,  without 
any  palpable  changes  in  its  structure,  through  alterations  in  the 
circulation. 

Hesky,  ^  observed  the  occurrence  of  Cheyne-Stokes  breathing 
during  the  course  of  a  fatal  case  of  enteric  fever.  The  chief  point 
of  interest  in  his  description  is  the  fact  that  the  pulse  almost  ceased 
during  the  long  pauses ;  the  pulsation,  indeed,  appeared  to  become 
less  before  the  respiration  began  to  diminish.  The  section 
gave  evidence,  in  addition  to  the  characteristic  abdominal 
lesions,  of  congestion  of  the  brain  and  medulla,  particularly  of  the 
floor  of  the  fourth  ventricle,  and  more  especially  of  the  points  of 
origin  of  the  vagus  and  hypoglossus.     The  author  is  of  opinion 

1  Wiener  medicinische  Wochenscrift,  Band  xix.  S.  1447  und  1464   1869. 

2  Wiener  medicinische  Presse,  x.  Jahrgang,  S.  1107  und  1133,  1669. 


I 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   KESPIEATION.  595 

that  the  cause  of  the  symptom  is  a  smaller  access  of  oxygenated 
blood  to  the  centres,  produced  by  the  lessened  activity  of  the 
circulation. 

Esenbeck^  describes  the  case  of  a  man,  aged  62,  belonging  to  an 
apoplectic  family,  and  subject  to  no  affection  beyond  nervous  palpita- 
tion, who  had  about  a  year  and  a  half  before  been  attacked  by 
apoplexy,  which  passed  away  without  leaving  any  distinct  sequelse 
in  its  train.  He  was  again  suddenly  seized  with  unconsciousness 
accompanied  by  convulsive  twitchings  of  the  face  and  right  arm, 
which  became  absolutely  paralysed.  Seven  days  after  the  attack  the 
patient  died  in  a  comatose  state.  Thirty-six  hours  before  death 
the  rhythm  of  Cheyne-Stokes  breatliing  appeared,  and  continued 
until  death  occurred.  On  section,  fatty  degeneration  of  the  heart 
was  found.  The  skull  was  very  thick,  the  meninges  and  ventricles  of 
the  brain  contained  a  considerable  amount  of  exudation,  the  vessels 
were  turgid,  and  the  brain  substance  showed  "  capillary  apoplexy," 
but  no  patch  of  cerebral  haemorrhage.  The  medulla  was  quite 
normal  in  appearance.  The  author  points  out  tliat  the  result  of 
the  post-mortem  examination  agrees  with  what  has  been  described 
by  Stokes  and  Traube,  and  gives  his  adhesion  to  the  theory  advanced 
by  the  latter. 

Leube,^  mentions  three  cases  which  he  observed  in  von  Ziemssen's 
clinique  presenting  this  syn)ptom,  one  being  an  instance  of  fatty 
degeneration  of  tlie  heart,  anotlier  of  cerebral  haemorrliage,  and  a 
third,  which  he  narrates  at  length,  of  mitral  stenosis  with  dilatation 
of  the  right  ventricle,  venous  pulsation,  hydrothorax,  ascites,  and 
albuminuria,  in  which  the  characteristic  rhythm  of  the  respiration 
came  on  after  a  subcutaneous  injection  of  morphine.  He  remarks 
that  at  the  beginning  of  the  pause  the  pupils  were  contracted  and 
underwent  no  change  in  size  with  alteration  of  liglit,  and  continued 
in  this  state  throughout  the  pause.  With  the  first  returning  breath, 
or,  rarely,  immediately  before  it,  they  dilated  again.  With  the 
movement  of  the  pupils  there  was  a  peculiar  lateral  deviation  of 
the  globes  of  the  eyes,  which  M'as  repeated  with  each  change  of 
the  size  of  the  pupils.  With  the  commencement  of  respiration 
the  globes  became  still,  and  during  the  respiratory  period  they 
performed  the  usual  movements  in  every  direction.  He  also  observes 
that  consciousness  was  entirely  lost  during  the  pauses,  and  further 
notes  that  during  this  phase  the  pulse  was  always  smaller  and  more 
irregular  than  during  the  periods,  but  that  the  rate  was  unaltered 
or  slightly  increased.  He  attributes  the  pupillary  changes  to  the 
action  of  the  excess  of  carbonic  acid  in  the  blood  on  the  oculo- 
pupillary  centre,  and  refers  to  the  observations  of  Vigouroux  on 
the  action  of  the  iris  in  inspiration  and  expiration,  and  to  the 
researches  of  Kiissmaul  on  the  influence  of  the  circulation  on  it,  as 
well  as  to  the  investigations  of  Adamtik  on  stimulation  of  the 

*  Aerzliches  hitelligemblatt,  S.  253,  1870. 

2  Berliner  Klinische  Wochenschrift,  \u.  Jalirgang,  S.  177,  1870. 


596  THKNOMENA   IN    CIIEYNE-STOKES   RESPIEATION.  [jAN. 

corpora  quadrigemina.  Lastly,  he  mentions  that  in  spite  of  deep 
inspirations  produced  by  electric  stimulation  of  the  phrenic  nerves, 
the  onset  and  course  of  the  period  of  breathing  were  unaffected. 
He  notes  that  each  deep  inspiration  thus  produced  by  artificial 
stimuli  was  accompanied  by  dilatation  of  the  pupils  ;  this,  however, 
he  says  may  be  due  to  stimulation  of  the  sympathetic  in  the  neck 
by  the  current. 

{To  he  continued.) 


II.— THE    INFLUENCE   OF   CERTAIN  MEDICINAL   AGENTS 
UPON  THE  BACILLUS  OF  TUBERCLE  IN  MAN.^ 

By  G.  Hunter  Mackenzie,  M.D.  Edin.  ;  Vice-President  for  Scotland, 
British  Laryngological  and  Rhinological  Association. 

The  subject  of  this  paper  is  one  of  great  interest  alike  to  the 
general  physician  and  to  the  laryngologist.  To  the  latter  it  is 
particularly  so,  as  to  him  it  pertains  more  especially  to  treat  those 
tubercular  lesions  which,  from  being  situated  in  the  upper  respira- 
tory regions,  are,  or  ought  to  be,  more  amenable  to  local  medica- 
tion than  such  as  are  located  in  the  lungs. 

Before  proceeding  to  my  subject  proper,  it  may  be  as  well  to 
glance  briefly  at  the  conditions  which  accompany  the  presence  of 
tubercle-bacilli  in  the  respii'atory  organs  and  tract,  and  in  the 
sputum. 

What  are  the  prospects  of  an  individual  with  tubercle-bacillary 
development  and  tubercle-bacillary  sputum  ? 
^  M.  Germain  See^  says,  "It  is  the  bacillus  which,  a  priori,  should 
<''^  decide  the  lot  of  the  patient.  Theoretically  this  may  be  true.  I 
am  convinced,  however,  from  numerous  observations  that,  so  far 
as  life  is  concerned,  the  outlook  in  such  cases  is  frequently  not  so 
gloomy  as  the  acceptance  of  this  dictum  would  lead  one  to  infer. 
Thus  a  patient  in  whose  expectoration  I  found  these  bacilli  for  the 
first  time,  nearly  six  years  ago,  while  repeated  examinations  every 
year  since  then  have  continued  to  reveal  their  presence  in  numbers 
varying  from  about  150  to  300  (x  450),  has  had  scarcely  any 
fever,  and  has  markedly  increased  in  weight  during  this  period. 
The  remarkable  thing  is  that  for  all  these  years  she  has  hardly 
ever  felt  indisposed.  In  another  patient  I  found  them  plentiful 
in  the  expectoration  five  years  ago.  I  continued  to  make  examina- 
tions of  the  sputum  for  about  three  years — bacilli  were  always 
present.  Neither  during  that  time,  nor  since,  has  the  patient  felt 
more  than  very  slightly  indisposed,  and  that  very  occasionally. 
In  another  case  I  found  them  in  the  sputum  four  years  ago :  the 

^  Read  before  the   British   Laryngological  and   Rhinological  Association, 
London,  l4th  November  1888. 
2  Bacillary  Phthisis,  English  Translation,  p.  228. 


1889.]  BACILLUS   OF   TUBEKCLE   IN   MAN.  597 

patient  has  had  one  or  two  attacks  of  what  was  described  as 
"catarrhal  pneumonia"  since,  but  is  now  in  tolerable  health. 

I  might  enumerate  many  similar  cases  which  have  come  under 
my  notice,  but  those  referred  to  will,  1  think,  justify  us  in  as- 
suming that  the  presence  of  tubercle-bacilli  in  the  sputum  is  not, 
per  se,  a  grave  indication  so  far  as  life,  and  even  tolerably  fair 
health  are  concerned.  They  do  not  in  any  way  decide  the  lot  of  I 
the  patient. 

Nor  do  the  numbers  in  which  these  organisms  are  present  iu 
the  sputum  necessarily  add  to  the  gravity  of  the  case.  I  except 
from  this  rule,  however,  those  instances  in  which  they  are  so 
persistently  abundant  as  to  be  beyond  power  of  enumeration,  and 
especially  when  singly,  or  combined  in  twos  or  threes,  they  present 
comma-shaped  outlines.  But,  speaking  generally,  I  concur  with* 
Germain  Se(5^  when  he  says  that  "the  multiplicity  of  these  para- 
sites does  not  in  any  way  indicate  the  gravity  of  the  lesion." 

There  are,  however,  certain  symptoms  and  collateral  conditions 
which,  plus  the  bacillus,  may  materially  aid  us  in  forecasting  the 
lot  of  the  patient. 

The  most  important  symptoms  are  fever,  and  consequent  loss 
of  body-weight.  Tubercle-bacilli  within  the  organism  are  not 
necessarily  productive  of  fever.  The  evening  temperature  in 
many  cases  ranges  from  98°  to  98°*5,  or  at  most  to  99°;  the  body- 
weight  may  increase,  and  all  the  while  bacilli  may  be  found  per- 
sistently present  in  fair  average  numbers  in  the  sputum.  What- 
ever may  be  the  immediate  cause  of  the  phthisical  pyrexia,  it  is 
certainly  not  due  to  the  mere  presence  of  the  bacilli.  On  the 
other  hand,  I  have  seen  comparatively  few  bacilli  accompanied  by 
a  marked  state  of  fever :  this  is  a  most  ominous  combination — a 
great  deal  more  so  than  many  bacilli  and  slight  or  no  fever.  I 
shall  not  now  attempt  an  elucidation  of  these  points,  but  content 
myself  with  stating  the  simple  facts. 

The  principal  collateral  condition  which  materially  contributes 
towards  deciding  the  lot  of  the  patient  is,  the  locality  of  the 
tubercular  lesions. 

I  have  already  brought  under  your  notice  the  cases  of  several 
individuals  who  have  led  tolerably  comfortable  lives  for  years 
with  tubercle-bacillary  sputa  persistently  present  throughout  the 
period  of  observation.  In  all  these  cases  the  seat  of  the  lesions 
was  the  lungs.  When  the  larynx  or  pharynx  has  been  the 
locality,  or  one  of  the  localities,  of  the  lesions,  the  course  of  the 
case  has  been  very  different,  for  I  have  rarely  witnessed  a  case  of 
genuine  tubercle-bacillary  disease  of  the  larynx  or  pharynx  with-, 
out  its  undergoing  rapid  deterioration.  Bacilli,  plus  laryngeal  or 
pharyngeal  lesions,  do  decide  the  lot  of  the  patient :  there  is  no 
mistake  about  this.  They  may  be  said  simply  to  swarm  in  the 
acute  variety  of  laryngeal  phthisis.  ^^ 

^  Bacillary  Phthisis,  English  Translation,  p.  233. 


598  DR   G.   HUNTER   MACKENZIE   ON    THE  [jAN. 

I  am  unable  to  assign  a  definite  reason  why  these  bacilli  be- 
come engrafted  upon  a  case  of  chronic  laryngitis,  or  lay  hold  of 
the  larynges  of  certain  subjects  of  pulmonary  tubercle-bacillary 
disease  and  not  of  others.  I  do  not  believe  that  they  come  from 
the  pulmonary  expectoration  in  transit,  for  I  have  never  yet  been 
able  to  detect  them  in  the  secretion  of  the  non-tubercular  larynx 
in  cases  of  pulmonary  tubercle-bacillary  disease.  If  in  such 
cases  one  could  find  them  in  the  secretion  of  the  larynx  hefore 
structural  evidences  of  their  presence  were  visible,  one  might 
assume  that  they  were  derived  from  the  pulmonary  expectoration. 
But  such  is  not  the  case. 

Whilst  tubercle-bacilli,  as  already  stated,  may  persist  in  the 
expectoration  of  certain  subjects  of  tubercle-bacillary  disease  for 
years  with  no,  or  slight  apparent  results  upon  the  general  economy, 
and  without  inducing  pyrexia  or  appreciable  progressive  local 
changes,  still,  in  view  of  the  fact  that  they  are  now  considered 
by  most  competent  authorities  the  essential  factor  in  the  pro- 
duction of  tubercular  disease,  the  most  important  indications  of 
treatment  is  to  get  rid  of  them.  How  is  this  to  be  accomplished? 
My  paper  this  evening  is  a  short  summary  of  many  therapeutic 
observations  made  in  this  direction. 

It  may  be  assumed  that  there  are  three  principal  methods  by 
which  we  may  endeavour  to  influence  the  bacillus  of  tubercle, 
namely,  by  climate,  by  general,  or  by  local  remedies.  Combina- 
tions of  tliese  may,  of  course,  also  be  essayed. 

In  watching  and  estimating  the  effects  of  different  climates 
upon  these  organisms  one  cannot  help  being  impressed  with  two 
facts, — the  obstinate  persistence  of  the  bacillus,  and  the  remark- 
ably small  amount  of  difference  between  the  anti-bacillary  virtues 
of  the  most  diverse  climates.  Thus  I  have  several  times  sent 
patients  round  the  world,  sometimes  with  a  short  sojourn  in  Aus- 
tralia, and  they  have  uniformly  returned  in  much  the  same  con- 
dition as  when  they  set  out,  so  far  at  least  as  the  bacilli  were 
concerned.  I  have  during  successive  seasons  sent  the  same 
patient  to  Switzerland,  the  Riviera,  and  Algeria,  without  appar- 
ently influencing  the  numbers  of  bacilli  in  the  sputum.  In  one 
case,  the  bacilli  appeared  to  increase  after  leaving  this  country  for 
the  Riviera,  and  in  another  the  same  thing  happened  after  going 
to  Algeria.  In  one  patient  I  found  that  almost  continuous  resi- 
dence for  nearly  three  years  in  the  Upper  Engadine,  whilst  pro- 
ductive of  great  benefit  to  the  patient's  general  health,  and  followed 
by  a  gain  of  34  lbs.  in  thirty  months,  failed  to  drive  the  bacilli 
from  the  expectoration.  I  have  compared  the  effects  of  residence 
on  the  sea  (yachting)  with  residence  on  shore,  and  have  been  un- 
able to  detect  any  difference  in  the  result  so  far  as  the  bacillary 
character  of  the  sputum  was  concerned. 

I  may  summarize  on  this  point  by  setting  forth  the  statement, 
based  on  a  fair  number  of  observations,  continued  in  some  instances 


1889.]  BACILLUS   OF   TUBERCLE   IN   MAN.  599 

for  years,  that  I  have  never  yet  witnessed  the  complete  disappear-  [ 
ance  of  tubercle-bacilli  from  the  sputum  follow  on,  or  be  induced  i 
by  climatic  changes.  The  climate  which  has  given  most  promise 
— certainly  not  marked — of  proving  inimical  to  their  growth  is 
one  which  is  dry,  with  the  minimum  variation  of  temperature, 
wliich  ought  to  be  rather  low  than  high.  One  beneficial  aspect  of 
a  low  temperature  is  its  tendency  to  diminish  the  amount  of 
expectoration,  a  result  which  almost  always  accords  with  a  diminu- 
tion in  numbers  of  the  bacilli.  If  the  hygrometric  conditions 
are  too  low  (air  too  dry),  there  is  a  risk  of  increased  irritation  of 
the  bronchial  mucous  membrane  and  ensuing  difficulty  in  expec- 
toration. 

So  far  as  general  remedies  are  concerned  I  have  little  to  say.     I 
have  frequently  examined  tlie  sputa  of  patients  before,  during,  and 
after  courses  of  treatment  by  almost  all  the  vaunted  remedies  and  ( 
specifics,  and  am  quite  certain  that  not  the   slightest  effect  was  I 
produced  by  any  of  tliem.     To  those  who  are  desirous  of  investi-  ' 
gating  this  part  of  the  subject,  I  may  direct  attention  to  the  state- 
ment of  Leyden,  that  alcohol,  by  internal  administration,  has  an 
antiseptic  action  on  the  pulmonary  secretions,  and  that  potash  is 
abundantly  present  in  catarrhal  (bacillary)  sputum,^  whilst  soda  is 
sparingly  found.     Alcohol  should  in  this  view  be  administered  to,  / 
whilst  potash  ought  to  be  witheld  from  tubercle-bacillary  cases. 
I  cannot  as  yet  speak  as  to  the  results  of  this  treatment  on  the 
bacilli. 

The  subject  of  local  medication  will  probalily  be  tlie  most 
interesting  to  the  members  of  this  Association.  What  is  the  value, 
apart  from  soothing  or  sedative  effects,  and  judged  by  the 
bacillary  test,  of  the  topical  medicinal  treatment,  antiseptic  or 
other,  of  tubercular  lesions  ?  It  ought  to  be  borne  in  mind  that 
an  efficient  antiseptic  must  possess  both  positive  and  negative 
qualities — it  must  be  destructive  to  the  bacillus  and  innocuous  to/ 
its  host.  Were  it  not  for  the  latter  essential  quality,  it  would  not/ 
be  difficult  to  select  a  host  of  bacilli  destroyers. 

I  think  I  can  affirm  that  bacilli  may  be  found  in  the  secretion 
of  the  tubercular  larynx  befoi'e  ulceration  has  taken  place,  that  is 
to  say,  in  the  stage  of  infiltration  or  thickening, — a  period  of  the 
disease  which  it  is  occasionally  difficult  to  distinguish  from  simple 
chronic  laryngitis.  In  fact,  I  have  not  unfrequently  made  use  of 
the  bacillary  test  to  distinguish  between  these  two  conditions, 
more  especially  when  the  former  has  supervened  upon  the  latter, — 
a  process  which  I  have  had  the  opportunity  of  carefully  observing 
in  a  few  cases,  and  of  the  existence  of  which  I  am  therefore 
thoroughly  convinced. 

Whether,  then,  the  condition  of  the  tubercular  larynx  be  one  of 
infiltration,  or  of  infiltration  plus  ulceration,  the  bacillus  is  there. 
It  is  unnecessary  for  me  to  eimmerate  the  methods  by  which  local 
^  Bamberger,  quoted  by  Riegel,  Ziemssen's  Cydopcedia,  vol.  iv.  j).  343. 


i 


600  Dll   G.    HUNTER   MACKENZIE   ON   THE  [jAN. 

medication  may  be  carried  on.  I  would  merely  remark,  that,  in 
order  to  allow  the  medicament  to  act  upon  the  diseased  parts,  it  is 
necessary  in  all  cases,  before  attempting  topical  medication,  to  effect 
ja.  preliminary  cleansing  of  the  affected  areas  from  all  mucus  or  pus. 

Probably  no  drug  has,  for  its  supposed  aseptic  properties,  been 
more  employed  in  the  local  treatment  of  tubercle-bacillary  lesions 
than  iodoform.  For  many  years  it  was  the  remedy  par  excellence, 
and  records  of  cases  were  not  wanting  in  which  its  marvellous 
powers  in  this  class  of  disease  were  apparently  placed  beyond  doubt. 
As  I  have  used  the  drug  very  largely,  and  made  very  many  obser- 
vations on  its  effects  upon  the  bacilli  of  tubercle,  I  select  it  prin- 
cipally as  an  example  of  remedies  administered  by  insufflation. 
Though  insufflation  has  been  the  principal  mode  in  which  I  have 
employed  it,  I  have  occasionally  aided  this  by  internal  administra- 
tion and  by  inunction. 

I  may  refer  to  a  case  published  by  me  in  the  Lancet,^  in  whicli 
the  bacillary  results  of  application  of  iodoform  to  the  larynx,  its 
internal  administration  and  inunction,  all  combined,  are  recorded  in 
great  detail.  I  there  say  that  "  treatment  by  iodoform  was  pushed 
as  far  as  was  considered  judicious  (iodic  intoxication),  but  without 
effecting  any  reduction  in  the  number  of  the  bacilli,  although  it 
diminished  the  putrefactive  odour  of  the  sputum." 

The  same  results  have  been  obtained  by  me  in  many  other  cases 
of  laryngeal  phthisis,  and  I  cannot  but  conclude  that  iodoform  is 
an  inert  drug  in  this  complaint. 

Heyn  and  Eovsing^  distinctly  assert  that  inoculation  of  a  certain 
quantity  of  tuberculous  material,  accompanied  by  a  relatively 
large  quantity  of  iodoform  is,  in  all  cases,  follow^ed  by  local,  and 
subsequently  by  general  tuberculosis.  Not  only  so,  but  they  affirm 
that  iodoform  appears  to  exercise  an  irritant  action  on  the  tissues, 
more  especially  upon  delicate  tissues  such  as  the  iris,  and  this 
irritation  seems  to  render  such  tissue  a  favourable  soil  for  the 
development  of  tuberculosis.  Jeffries,^  as  the  result  of  a  careful 
experimental  inquiry,  came  to  the  conclusion  that  iod^j'orm  js.jQOt 
a  germicide;  it  has  a  decided  tendency  to  stop  serous  oozing,  and 
is  therefore  indicated  in  wounds  where  the  moisture  threatens  the 
integrity  of  the  aseptic  and  antiseptic  dressing.  It  has  further 
been  found  that,  when  to  a  virulent  culture  of  the  bacillus  a  strong 
jdose  of  iodoformized  ether  is  added,  the  culture  is  arrested  although 
!a  temperature  favourable  to  its  growth  is  maintained.  It  even  seems 
ito  fade  away,  and  yet  a  month  afterwards,  the  induction  of  tuber- 
'culosis  is  as  readily  as  ever  effected  by  it.* 

I  have  for  some  time  back  entirely  discarded  iodoform  in  the 
treatment  of  tubercle-bacillary  disease. 

1  Lancet,  1885,  vol.  i.  p.  187. 

2  Quoted  by  MM.  Filleau  and  Leon- Petit,  Curabilitede  laphtisie,  May  1887. 
^International  Journal  of  the  Medical  Sciences,  January  1888. 

*  Bulletin  du  laboratoire  des  docteurs,  A.  Filleau  et  Leon-Petit,  May  1887. 


1889.]  BACILLUS   OF   TUBERCLE    IN    MAN.  601 

Tlie  method  of  spraying  may  be  employed  for  the  application  of 
antiseptic  medicaments  to  tubercle-bacillary  lesions,  as,  for  instance, 
to  those  of  the  larynx.  By  this  metliod  I  have  made  use  of  carbolic 
acid,  iodine,  corrosive  sublimate,  and  other  antiseptics.  The  mode 
of  operating-  has  been  for  the  patient  to  use  a  Siegel's  steam  spray 
four  or  five  times  daily,  from  two  to  five  minutes  at  a  time.  This 
is  to  be  continued  from  one  to  three  months,  and  the  sputum  to 
be  examined  twice  weekly.  The  result,  even  with  the  bichloride 
of  mercury  (1  in  2500),  has  been  the  same  as  with  iodoforn), 
absolutely  nil.  These  sprayings,  it  may  be  remarked,  if  used  too 
frequently  or  for  too  prolonged  a  period,  tend  to  induce  nausea 
and  vomiting,  and  the  bichloride  of  mercury  blackens  the  teeth 
and  tongue. 

I    consider   dry   inhalations    as    distinctly    contraindicated   in  t\ 
laryngeal  disease,  on  account  of  their  desiccating  and  irritating  ] 
effect  upon  the  laryngeal  mucous  membrane.     I  have  accordingly 
for  years  given  up  their  use  in  tubercle-bacillary  disease  of  the 
larynx,  but  have  made  a  number  of  prolonged  observations  of  their 
effects  in  the  pulmonary  variety  of  the  disease.     In  this  way  I 
have  used  carbolic-acid,  creasote,  eucalyptus,  iodine,  and  bromine, 
putting  a  few  drops  of  one  or  otlier  of  these  medicaments  upon  the 
S[)onge  of  an  oro-nasal  respirator,  and  causing  the  patient  to  breathe   i 
the  same  for  eight  to  ten  hours  daily  for  periods  varying  from  six   \ 
weeks  to  twenty  months.     In  no  single  instance  have  i  been  able 
to  satisfy  myself  that  they  influenced  in  the  slightest  degree  the 
bacilli  of  tubercle.     In  one  case  already  recorded  by  me  with 
illustrative  charts,^  and  treated  by  this  system  for  a  period  of 
twenty  months,  the  bacilli  actually  increased  in  numbers  during  a 
most  conscientious  carrying  out  of  this  treatment. 

The  problem  of  affecting  the  germ  of  tubercle  by  either  general 
or  local  medicinal  agents  has  not  yet  been  solved.  The  character 
of  this  organism  has  been  fully  and,  I  am  afraid,  accurately 
described  by  MM.  Filleau  and  L^on-Petit^  as  follows: — 'The 
bacillus  of  tubercle  is,  of  all  micro-organisms,  one  of  the  most 
refractory  to  the  action  of  the  most  destructive  agencies.  It 
maintains  its  virulence  after  lying  for  forty  days  in  putrid  sputum, 
and  for  one  hundred  and  eighty  six  days  away  from  contact  with 
air.  It  can  live  at  temperatures  between  86°  and  104°  F.  The 
most  unfavourable  conditions,  though  affecting  its  activity,  do  not 
compromise  its  existence,  for  it  resumes  its  virulence  whenever  its 
surroundings  become  suitable.  To  render  it  inactive,  it  is  necessary 
to  have  recourse  to  violent  means,  such  as  ebullition,  steaming,  or 
prolonged  contact  with  antiseptic  substances,  such  as  ammonia, 
concentrated  salicylic  acid,  absolute  alcohol,  or  a  strong  solution  of 
carbolic  acid.  Corrosive  sublimate  itself  is  powerless  to  disinfect 
the  sputum  (Schill  and  Fischer). 

^  A  Practical  Treatise  on  the  Sputum,  1886,  p.  78. 

^  Le  Crachat,  by  Hunter  Mackenzie  and  Leon-Petit.   Footnote,  p.  133. 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    VII.  4  0 


'/ 


602  BACILLUS   OF   TUBERCLE   IN    MAN.  [jAN. 

"  The  bacillus  acclimatizes  itself  amid  the  most  unfavourable 
surroundings.  It  complies  with  the  exigencies  of  its  conditiou,  and 
even  alters  its  shape,  but  without  losing  any  of  its  virulence, of  which 
it  gives  ample  evidence  whenever  fortune  favours  it.  Its  poly- 
morphism is  not  the  least  curious  point  in  the  life-history  of  this 
organism.  Thus  it  is  sometimes  a  short  rod,  sometimes  a  line — 
occasionally  it  splits,  and  forms  spores — but  it  always  returns  to 
the  bacillus  in  its  complete  form  with  its  virulence  intact,  whenever 
circumstances  become  favourable.  '  It  knows  how  to  suffer,  but  it 
never  loses  sight  of  its  claims.'  " 

Gentlemen,  in  view  of  the  above  facts  I  am  a  sceptic  in  regard 
to  the  curability,  by  medicinal  agents,  of  tubercular  lesions,  i.e., 
lesions  due  to  the  bacilli  of  tubercle,  and  in  which  their  presence 
can  be  demonstrated.  (This  assertion  does  not,  of  course,  embrace 
what  are  essentially  surgical  measures,  such  as  scraping,  galvano- 
or  thermo-cauterizations,  and  tracheotomy.)  Antiseptics  in  bacil- 
licidary  strength  as  regards  concentration  and  period  of  application 
cannot  be  borne  by  man,  and  what  result  can  be  expected  from 
the  application  of  a  few  grains  of  a  powder,  the  intermittent  use  of 
a  spray,  or  a  short  residence  in  a  southern  clime,  or  on  an  Alpine 
height,  in  the  case  of  an  organism  which  is  not  only  extremely 
tenacious  of  life,  but  when  unfavourably  suited  for  growth,  is 
always  prepared  to  "  bide  its  time,"  and  bud  and  blossom  afresh 
whenever  it  returns  to  favourable  conditions  ? 


\ 


III.— CASE  OF  GANGRENE  OF  THE  TRANSVERSE  COLON 
IN  AN  UMBILICAL  HERNIA ;  REMOVAL  OF  22  INCHES  OF 
GUT;  SUTURE  OF  THE  INTESTINE:  RECOVERY. 

By  J,  M.  CoTTERiLL,  Assistant  Surgeon,  Edinburgh  Royal  Infirmary. 

{Read  before  the  Medico- Chirurgical  Society  of  Edinburgh,  5th  December  1888.) 

In  the  spring  of  the  present  year,  I  mentioned  at  one  of  the 
meetings  of  the  Medico -Chirurgical  Society  the  case  of  a  patient 
from  whom  I  had  removed  a  large  piece  of  gangrenous  transverse 
colon.  The  patient  recovered  from  that  operation  with  an  artificial 
anus  at  the  umbilicus,  and  I  said  that  I  hoped  to  complete  the 
cure  by  some  further  operation,  and  report  the  case  more  fully  at 
a  later  date.  Accordingly,  this  evening  I  propose  to  read  a  short 
history  of  the  case  from  its  commencement,  and  to  discuss  briefly 
such  points  of  interest  as  suggest  themselves. 

Mrs  R.,  aged  38,  was  admitted  from  the  Maternity  Hospital  into 
Ward  VIII.  of  the  Royal  Infirmary  on  14th  April  suffering  from 
umbilical  hernia.  The  previous  history  of  the  case  was  to  the 
effect  that  the  patient  had  suffered  for  seven  years  from  an 
umbilical  hernia  of  large  size,  which,  however,  had  never  given  any 


1889.]  GANGRENE   OF   THE   TKANSVERSE   COLON.  603 

trouble  till  ten  days  before  admission.  At  that  time  the  patient 
reports  that  she  took  a  long  walk,  that  the  streets  were  slippery, 
and  that  she  fancied  she  had  strained  herself  by  recovering  herself 
in  slipping.  When  she  reached  home  the  rupture  was  swollen 
and  painful.  Fomentations  were  applied,  but  as  in  a  week's  time 
she  was  no  better  she  sent  for  her  medical  attendant.  At  this 
time  Mrs  R.  was  seven  months  pregnant,  and  as  no  success  followed 
the  attempts  at  taxis,  a  firm  binder,  which  the  patient  was  in  the 
habit  of  wearing,  was  reapplied,  and  she  was  sent  to  the  Maternity 
Hospital,  as  it  was  feared  she  was  about  to  miscarry.  The  patient 
herself  was  under  the  impression  that  the  cliild  had  been  dead 
three  or  four  days.  At  the  Maternity  Hospital  no  improvement 
took  place,  so  she  was  transferred  to  Professor  Annandale's  Wards 
in  the  Infirmary,  of  which  I  happened  to  be  in  charge  at  the  time. 

On  admission  the  following  notes  were  taken : — The  patient  is  a 
strong-looking  woman,  but  enormously  fat,  being  some  eighteen 
stone  weight.  At  the  summit  of  a  large  fat  abdomen,  distended 
by  a  uterus  seven  months  pregnant,  is  a  bright-red,  angry  looking, 
brawny  swelling  about  fourteen  inches  in  diameter,  and  projecting 
some  four  inches  from  tlie  general  outline  of  the  abdominal  profile. 
The  patient  is  anxious  and  in  pain,  and  the  face  is  pinched.  Pulse, 
110;  temperature,  100''*2.  No  vomiting  had  taken  place  before 
her  admission  to  the  Infirmary,  but  as  it  came  on  a  few  hours 
afterwards,  I  was  sent  for.  I  found  that  she  had  vomited  about 
six  ounces  of  a  coffee-coloured  fluid  containing  blood;  her  pulse 
and  temperature  were  rapidly  rising,  and  she  was  evidently  getting 
much  worse. 

I  accortlingly  determined  to  operate  at  once,  and  with  the 
assistance  of  Dr  Hodsdon  and  Dr  George  Keith  I  freely  opened  up 
the  swelling  by  an  incision  some  ten  inches  in  length.  When  the 
sac  was  opened  it  was  found  to  contain  a  large  coil  of  gangrenous 
transverse  colon,  several  large  masses  of  omentum  adherent  to 
the  sac  and  also  gangrenous,  and  fluid  fteculent  matter  which  had 
escaped  from  the  ruptured  gut. 

There  appeared  to  be  no  strangulation  at  all  at  the  umbilical 
opening,  and  the  gangrene  seems  to  have  been  caused  by  the 
pressure  brought  to  bear  on  the  contents  of  the  hernia  between 
the  firm  binder  above  and  the  pregnant  uterus  below. 

We  proceeded  to  cut  away  fifteen  inches  of  colon  which  was 
absolutely  gangrenous  or  beyo'ud  recovery,  cleared  out  the  putrid 
omentum  and  most  of  the  sac,  and  having  washed  the  wound  out 
thoroughly  with  sublimate  lotion,  stitched  the  cut  ends  of  the  gut 
to  the  edges  of  the  skin  wound,  and  got  the  patient  back  to  bed  in 
an  apparently  dying  condition. 

I  will  not  detain  you  by  a  detailed  account  of  the  fight  between 
life  and  death  for  the  few  days  following  the  operation ;  how  a 
condition  of  profound  collapse,  as  evidenced  by  a  fluttering  pulse 
of   160,  Cheyne-Stokes  respiration,  and  delirium,  gradually  gave 


604  Mil  J.    M.    COTTERILL's   case   of   gangrene   of   the        [JAN. 

way  before  assiduous  treatment.  On  the  second  day  after  the  opera- 
tion tlie  bowels  moved  through  the  wound  for  the  first  time.  On 
the  day  following,  i.e.,  17th  April,  the  patient  miscarried.  A  seven 
months'  child  was  born  alive  with  one  pain,  the  whole  labour 
being  over  in  the  course  of  three  minutes.  The  child  survived 
about  two  days.  The  bowels  were  again  freely  moved  during  the 
labour,  and  there  was  considerable  post-partum  lunemovrhage. 

The  patient  seemed  to  be  considerably  relieved  by  getting  lier 
labour  over,  and  all  went  well  with  her  till  20th  April,  when,  after 
a  severe  rigor  and  rise  of  temperature,  she  developed  an  attack  of 
phlegmasia  dolens,  first  in  the  left  leg,  and,  a  few  days  subsequently, 
in  the  right.  This,  however,  ultimately  cleared  up,  and  she  left  the 
Hospital  on  23rd  June  with  the  wound  well  contracted  and  healed 
round  the  artificial  anus.  The  bowels  at  this  time  were  acting 
loosely  about  six  times  a  day,  and  she  was  in  very  good  health. 

During  the  three  montlis  that  she  was  out  of  the  Infirmary  slie 
was  confined  a  good  deal  to  bed,  for  there  was  considerable  prolapse 
of  the  intestine  and  discharge  of  faeces  whenever  she  walked  about 
much.  Her  discomfort  was  so  great  that  she  expressed  a  very 
strong  wish  to  come  back  and  have  tlie  artificial  anus  cured  at  any 
price,  for,  as  she  expressed  it,  "she  would  much  rather  die  than  go 
on  as  she  was." 

J  had  thought  of  trying  to  close  the  artificial  anus  by  some 
modification  of  Dupuytren's  operation,  but  was  dissuaded  from  this 
by  finding  that  fiuids  injected  from  the  umbilical  opening  into  the 
lower  segment  of  gut  would  not  pass  per  anum,  but  regurgitated 
alongside  of  the  syringe.  This  appeared  to  be  due  to  a  kink  in  the 
gut  at  the  splenic  flexion  about  eight  inches  from  the  cut  end,  which 
kink  was  presumably  caused  by  the  dragging  of  the  gut  downwards 
towards  the  umbilicus.  The  patient  was  accordingly  prepared  for 
the  operation  of  resection  of  the  gut  and  suturing  of  its  free  ends. 
For  ten  days  previous  to  operation  she  was  directed  to  be  fed 
entirely  on  peptonized  fluids,  partly  by  the  mouth  and  partly  by 
the  bowel,  and  the  intestines  were  still  further  emptied  by  castor 
oil  and  several  enemata  both  from  the  umbilical  opening  and  from 
the  anus  proper.  This  last  proceeding  resulted  in  the  passage  of  a 
scybalous  mass  of  large  size  per  anum. 

The  operation  was  performed  on  30th  Sept.,  and  again  I  had  the 
assistance  of  Drs  Hodsdon  and  Keith.  Having  carefully  cleansed 
the  skin  around  the  opening  and  having  washed  out  the  two  cut 
ends  of  intestine,  I  put  a  ligature  round  the  upper  one  to  prevent 
faeces  escaping  into  the  wound,  and  then  I  freed  them  both  from 
the  adhesions  which  bound  them  to  the  umbilical  ring  and  surround- 
ing parts.  Gentle  traction  was  then  made  upon  the  two  ends  until 
normal  gut  covered  by  peritoneum  protruded  sufficiently  for  my 
purpose.  Instead  of  using  a  clamp  I  passed  a  piece  of  thin  india- 
rubber  tubing  through  a  small  hole  in  the  mesentery  and  round 
the  gut,  fixing  it  there  with  a  pair  of  catcli  forceps;  I  then  cut  away 


1889.]  TIIANSVERSE   COLON    IN    AN    UMBILICAL    IIEIINIA.  605 

four  inches  of  the  upper  segment  of  colon  and  three  inches  of  the 
lower,  with  portions  of  mesentery  attached.  The  two  pieces  of 
intestine  were,  as  usual  under  such  circumstances,  found  of  very 
unequal  size,  the  upper  segment  admitting  four  fingers,  while  the 
lower,  in  which  function  had  been  in  abeyance  for  five  months, 
would  only  just  admit  the  forefinger.  Though  I  succeeded  in 
dilating  it  a  little,  this  inequality  in  the  two  ends  added  very 
greatly  to  the  difficulty  of  the  operation.  Tins  difficulty  has  been 
got  over  in  one  or  two  cases  by  cutting  the  lower  bowel  away 
obliquely  from  its  mesenteric  attachment  so  as  to  increase  the  area 
to  be  sutured.  By  the  very  careful  passage  of  over  a  hundred 
stitches  I  was  able  to  get  the  ends  satisfactorily  together. 

I  used  fine  curved  needles,  round  like  a  dressmaker's  needle,  and 
threaded  witli  the  finest  Chinese  twisted  silk.  The  method  used 
was  the  modification  of  the  Lerabert  suture  by  Czerny,  i.e.,  a 
double  row  of  interrupted  sutures,  which  lie  completely  outside  tlie 
bowel,  and  are  passed  through  the  serous  and  muscular  coats  of  the 
intestine  alone.  The  outer  row  is  about  one-third  of  an  inch  out- 
side the  inner  row,  and  the  stitches  of  one  row  are  about  a  line 
distant  from  one  another. 

The  cut  edges  of  the  mesentery  were  then  sutured  together,  and 
the  gut  was  returned  into  the  abdomen.  The  large  umbilical  open- 
ing was  brought  together  by  deep  silk  stitches,  and  a  firm  pad  and 
binder  applied.  A  hypodermic  injection  of  ;^th  of  a  grain  of 
morphia  was  given,  and  the  patient  was  put  back  into  bed,  having 
been  just  three  hours  on  the  table. 

During  the  first  twenty-four  hours  after  the  operation  there  was 
a  little  fever  and  restlessness,  the  tempei'ature  once  rising  as  high 
as  102°,  but  in  a  day  or  two  it  became  practically  normal,  and  has 
remained  so  ever  since.  Wind  passed  freely  the  day  after  the 
operation,  and  the  day  following  there  was  a  free  liquid  movement 
of  the  bowels.  From  that  time  she  has  made  an  uninterrupted 
recovery,  the  bowels  moving  about  every  other  day.  She  was  fed 
exclusively  on  peptonized  fluids  for  three  weeks  after  the  operation, 
but  for  the  last  six  weeks  has  taken  soup,  porridge,  minced  chicken, 
etc.,  and  is  now  taking  ordinary  diet.  There  has  never  been  any 
pain  beyond  a  little  occasional  griping  from  the  passage  of  wind 
along  the  bowel ;  but  that  has  now  quite  ceased.  A  little  compound 
liquorice  powder  is  taken  every  two  or  three  days  to  keep  the  stools 
soft. 

She  was  discharged  from  the  Infirmary  on  25th  November  in 
excellent  health. 

Without  attempting  to  generalize  from  so  small  an  experience, 
there  are  certain  convictions  which  have  forced  themselves  upon 
me  in  connexion  with  this  case. 

Firstly,  that  it  is  of  the  utmost  importance,  even  in  the  case  of  a 
surgeon  who  is  frequently  operating,  that  this  operation  should  be 
practised  on  the  dead  body  before  trying  it  on  the  living.     The 


606  MR   J.    M.    COTTElilLL's    CASE   OF    GANGRENE    OF    THE        [jAN. 

confidence  that  one  lias  really  closed  the  gut,  and  the  celerity  in 
operating  which  are  obtained  by  such  practice,  cannot  be  too  highly 
valued,  for  one  cannot  test  by  any  means  on  the  living  body 
whether  the  sutures  liave  been  applied  in  such  a  way  as  to  render 
the  gut  water-tight  before  it  is  returned  into  the  abdomen ;  and  it 
is  most  important  not  to  waste  any  time  in  the  performance  of  an 
operation  which  is  very  tedious  at  the  best. 

Again,  judging  from  several  hours'  practice  of  the  operation,  I 
cannot  say  that  I  see  the  necessity  for  the  introduction  into  the 
lumen  of  gut  of  any  of  those  materials,  such  as  india-rubber  collap- 
sible bags,  lumps  of  cocoa-butter,  etc.,  which  have  been  used  for  the 
purpose  for  dilating  the  gut  during  the  process  of  suture.  As  a 
matter  of  fact,  I  believe  that  most  surgeons  who  have  had  any 
experience  of  the  operation  are  now  coming  to  this  opinion. 

With  regard  to  the  clamps  which  are  recommended  for  this 
operation,  though  I  liad  the  two  most  frequently  used  (Bishop's  and 
Treves')  by  my  side,  I  used  neither  of  them,  as  they  appeared  to 
hamper  one's  movements  very  considerably,  and  neither  of  them 
were  long  enough  in  the  blade  to  efficiently  clamp  the  large 
intestine.  The  piece  of  india-rubber  tubing,  applied  as  I  have 
described,  acted  adnurably.  The  best  form  of  clamp  appears  to  be 
that  of  Mr  Makins  of  St  Thomas's  Hospital.  It  is  less  complicated 
and  cumbersome  than  the  others,  and  has  the  advantage  botli  over 
the  method  I  used  and  over  Treves'  clamp,  that  no  wounding  of 
the  mesentery  is  necessary  for  its  application.  Tliis  is  somewhat 
important,  as  the  experiments  of  Eydygier  and  Madelung  go  to 
show  that  separation  of  the  gut  from  its  mesentery  is  apt  to  he 
followed  by  gangrene  of  the  bowel  at  the  denuded  part. 

The  idea  that  an  assistant's  fingers  should  take  the  place  of  a 
clamp  does  not  commend  itself,  for  neither  would  the  control  of 
the  gut  during  a  long  operation  be  so  reliable,  nor  does  this  plan 
leave  the  operator  so  mucli  room  to  work  in,  unless  more  healthy 
intestine  is  pulled  out  of  the  abdomen  than  would  be  necessary  if 
a  clamp  were  used. 

I  was  prevented  upon  the  occasion  of  the  first  operation,  by  the 
extreme  prostration  of  the  patient  and  the  intense  putridity  of  the 
parts  concerned,  from  suturing  the  gut  and  returning  it  into  the 
abdomen  at  once. 

It  has  been  established,  chiefly  by  statistics  drawn  up  by  Mr 
Makins,  that  the  best  results  after  resection  of  intestine  are 
obtained  in  cases  of  operation  for  the  cure  of  artificial  anus  (the 
mortality  in  this  class  being  38  per  cent,  as  contrasted  with  a 
mortality  of  about  50  per  cent,  when  all  cases  are  taken  together). 
In  other  words,  it  appears  less  hazardous  to  do  the  operation  in  two 
stages  rather  than  complete  the  operation  at  the  time  of  the 
removal  of  a  gangrenous  portion,  when  the  patient  is  frequently  in 
an  unsatisfactory  condition,  both  locally  and  generally,  for  such  a 
serious  proceeding.     It  is,  of  course,  undeniable  that  the  patient 


1889.]  TRANSVERSE   COLON   IN   AN    UMBILICAL   HERNIA.  607 

lias  in  the  former  case  to  undergo  two  operations  instead  of  one  in 
the  latter ;  but  it  seems  probable  that  this  apparent  disadvantage 
is  in  some  instances,  at  any  rate,  more  than  counterbalanced  by 
the  lessening  of  tlie  mortality  after  the  operation  when  it  is  done 
at  the  later  stage.  Upon  the  other  side  must  be  borne  in 
mind  the  increased  difficulty  in  the  secondary  operation  due  to 
shrinking  of  the  lower  disused  portion  of  intestine. 

Of  the  thirty-three  different  methods  of  suture  which  have  been 
recommended  for  the  purpose,  the  one  I  employed,  namely, 
Czerny's  modification  of  Lembert's,  is  most  in  favour.  It  cer- 
tainly appears  to  fulfil  the  chief  requirement  of  bringing  two 
broad  surfaces  of  the  peritoneal  aspect  of  each  segment  in 
good  apposition  with  one  another;  and  judging  from  experiment 
on  the  dead  body,  the  double  row  of  sutures  is  evidently  of 
service  in  preventing  the  immediate  escape  of  fluids  from  the 
sutured  bowel. 

A  study  of  the  reported  cases  of  resection  and  suture  of  intestine 
shows  that,  while  a  certain  number  of  successful  operations  have 
been  performed  on  the  small  intestine,  chiefly  by  German  surgeons 
(and  amongst  others  by  the  late  Dr  Angus  Macdouald,  who,  in  the 
course  of  an  operation  for  ectopic  gestation,  removed  some  six 
inches  of  small  intestine),  tiie  large  intestine  has  very  seldom 
been  successfully  dealt  with  in  like  manner. 

Mr  Hardie  {Medical  Chronicle,  Jan.,  1885)  reports  a  case  where 
he  resected  three  inches  of  colon  for  artificial  anus  with  a  successful 
result.  Mr  Kendal  Franks  has  within  the  last  few  days  published 
a  case  in  wliich  he  successfully  removed  a  large  epithelioma  with 
six  inches  of  colon ;  and  Professor  Weir  of  Xew  York  informed 
me  a  few  weeks  ago  that  he  had  in  one  case  resected  six  inches  of 
colon  with  a  good  result. 

In  the  case  I  have  brought  before  you,  no  less  than  twenty- two 
inches  of  large  intestine  were  removed  in  the  course  of  the  two 
operations. 


IV.-PERSONAL  EXPERIENCES  OF  A  WINTER  IN  THE 
CANARY  ISLANDS. 

By  H.  CouPLAND  Taylor,  M.D.,  F.R.  Metl.  Soc. 

As  so  many  members  of  the  medical  profession,  as  well  as  of  the 
general  public,  are  seemingly  anxious  to  know  what  the  prospects 
are  of  these  favoured  islands  affording  a  desirable  winter  resort  for 
those  who  require  a  warmer  and  more  equable  climate  tlian  that 
of  the  Riviera,  and  yet  a  drier  one  than  that  of  Madeira,  the 
following  personal  experiences  of  a  medical  invalid,  who  spent  last 
winter  in  them,  may  not  be  devoid  of  interest  to  those  inquiring 
as  to  their  suitability  for  invalids. 

The  island  of  Teneriffe  may  be  most  quickly  reached  and  with  the 
greatest  comfort  by  the  fine  ocean  steamers  of  either  Messrs  Shaw, 


608  DK    II.    C.   TAYLOK's   experiences   of   a  [JAN. 

Savill,  &  Co.,  or  of  the  New  Zealand  Shipping  Company,  both  of 
which  sail  monthly  from  London,  and  calling  at  Plymouth,  from 
which  they  take  only  four  and  a  half  to  five  days.  The  Castle 
Line  of  packets  to  the  Cape  call  at  Las  Palmas,  Grand  Canary, 
once  a  month.  Tiie  British  and  African  Company's  ships  sail 
weekly  from  Liverpool,  calling  both  at  Teneriffe  and  Grand  Canary, 
and  take  about  nine  days  on  the  voyage.  They  are  smaller,  slower, 
and  cheaper  boats  than  the  above-mentioned,  and  vary  very  nmch  in 
their  accommodation,  some  being  clean  and  good,  others  dirty  and 
uncomfortable. 

Las  Palmas,  the  capital  of  Grand  Canary,  faces  nearly  due  east, 
and  is  built  on  a  flat  strip  of  land  at  the  base  of  some  barren  hills, 
and  lies  between  them  and  the  sea.  The  town  has  a  very  Moorish 
appearance,  nearly  all  the  roofs  of  the  houses  being  flat,  and  many 
only  one  story  high.  I  landed  at  the  port,  which  is  about  four 
miles  from  the  town,  about  the  middle  of  October,  with  several 
other  invalids,  and  we  then  drove  along  a  very  dusty  bare  road  to 
the  English  hotel,  which  is  situated  in  the  town  of  Las  Palmas 
itself.  Even  at  that  time  of  the  year  we  found  the  heat  greatly  too 
oppressive  and  debilitating  for  those  who  are  not  strong,  and  it 
was  much  complained  of  by  those  both  there  and  at  Orotava. 
The  beginning  of  November  is  therefore  as  early  as  invalids  should 
arrive,  unless  they  go  direct  to  either  of  the  two  high  stations  in 
Teneriffe,  viz.,  Laguna,  2000  feet,  or  Villa  Orotava,  1200  feet,  at 
both  of  which  there  are  now  very  good  English  hotels,  and  at  both 
of  which,  indeed,  the  entire  summer  may  be  spent  without  incur- 
ring any  great  heat, — a  great  convenience  to  those  invalids  who  dare 
not  return  to  England  during  the  summer.  Many  of  the  residents 
in  Orotava  and  Santa  Cruz  go  up  to  these  places  with  their  families 
in  May  and  remain  till  October,  during  which  period,  Dr  G.  Victor 
Perez  of  Orotava  informs  me,  the  weather  is  most  pleasant. 

The  general  accommodation  and  food  in  the  hotels  at  Las  Palmas 
are  fair,  though  invalids  have  not  hitherto  been  much  considered, 
in  fact,  have  rather  been  thought  de  trop.  But  the  great  complaint 
against  them  is  that  they  are  all  essentially  badly  situated  for  in- 
valids, being  placed  more  or  less  in  the  streets  of  a  particularly 
noisy,  dirty,  and  odorous  town ;  neither  is  it  possible  within  an 
easy  walk  to  get  out  of  these  narrow  streets  for  fresh,  pure  air  and 
the  gentle  exercise  which  are  so  essential  for  the  phthisical.  The 
invalids  had,  therefore,  to  drive  daily  to  the  fine  sandy  beach 
about  a  mile  and  a  half  off,  a  quite  unattainable  distance  on  foot 
for  invalids  in  the  hot  sun  experienced  there,  and  spend  the 
morning  on  the  shore.  Often,  however,  as  there  was  no  shelter  of 
any  kind  to  be  obtained,  the  more  susceptible  of  the  invalids  found 
the  strong  and  cool  north-east  trade  wind  too  much  for  them,  and 
they  had  to  return  to  the  close  atmosphere  of  the  town  and 
hotel  rooms.  There  being  no  villas  to  be  obtained,  every  one  is 
forced  to  take  up  their  quarters  in  the  town  hotels.  Until,  tliere- 
fore,  there  is  accommodation   with   good    sanitary  arrangements 


1889.]  WINTER   IN   THE   CANARY   ISLANDS.  609 

provided  away  from  the  streets  of  the  town,  with  gardens,  shel- 
tered balconies,  and  such  like  conveniences  for  the  delicate,  so  that 
invalids  can  obtain  fresh  air  without  constantly  inhaling  the  foul 
odours  of  the  streets  of  a  drainless  town,  Las  Pal  mas  does  not  seem 
to  fulfil  the  elementary  requirements  of  a  health  resort.  Indeed, 
from  the  amount  of  illness  there  last  season  amongst  the  visitors, 
especially  diarrhoea  and  typhoid  fever,  the  former  of  which  almost 
universally  attacks  all  new-comers,  whether  healthy  or  delicate, 
whether  they  are  indiscreet  in  their  use  of  fruit  or  never  touch  it, 
it  appears  scarcely  a  satisfactory  winter  resort  for  any  one,  and 
many  and  great  have  been  the  disappointments  of  those  who  have 
gone  there  with  expectation  of  spending  a  pleasant  winter,  and  of 
returning  home  in  improved  health. 

Leaving  Grand  Canary  at  the  end  of  November,  I  spent  the  re- 
mainder of  the  winter  in  the  island  of  Teneriffe.  The  steamers  take 
about  six  hours,  or  frequently  a  night,  in  going  from  Las  Palmas  to 
Santa  Cruz,  the  chief  town  and  port  of  Teneriffe.  There  is  a  fair 
English  hotel  at  Santa  Cruz,  but  it  labours  under  the  same  disad- 
vantages as  those  at  Las  Palmas,  and  few  persons  stay  there  more 
than  a  day  or  two,  though  I  hear  an  English  boarding-house  has 
been  opened  this  season,  under  the  superintendence  of  an  English 
medical  man.  Though  at  present  neglected,  it  seems  probable  that 
for  tlie  months  of  January,  Eebruary,  and  March,  Santa  Cruz  has 
the  best  climate  in  the  islands,  for,  as  it  has  a  southern  aspect,  the 
clouds  which  so  constantly  gather  in  these  islands  and  Madeira 
around  the  high  mountains  and  extend  up  to  the  zenith,  do  not  inter- 
cept so  much  of  the  sunshine  as  in  those  places,  such  as  Orotava, 
which  are  situated  on  the  north  or  east  sides  of  the  islands.  Again, 
it  is  more  protected  from  the  cool  north-east  winds  to  which  those 
places  lie  exposed,  and  which  are  grateful  enough  later  on  in  the 
spring,  but  are  rather  trying  to  many  invalids  during  the  earlier 
months  of  the  year. 

From  Santa  Cruz  to  Orotava  is  a  long  six  or  seven  hours'  drive, 
the  road  passing  through  Laguna,  above  referred  to,  at  a  height  of 
nearly  2000  feet.  Many  find  this  drive  very  trying,  not  only  from 
its  tediousness  and  the  nature  of  the  carriages  employed,  but  also 
on  account  of  the  cold  winds,  fog,  and  wet  frequently  experienced 
during  the  winter  months  at  that  elevation.  It  is  most  injudicious, 
therefore,  for  persons  to  throw  aside  their  wraps  and  put  on  light 
underclothing,  as  they  are  so  apt  to  do  on  arriving  at  Santa  Cruz,  for 
several  cases  of  serious  chill  and  illness  were  caused  thereby  during 
last  season. 

On  arriving  at  Orotava,  I  found  that  the  Grand  Hotel  itself, 
which  had  been  so  highly  praised,  could  only  entertain  about 
twenty  persons ;  so,  like  the  vast  majority  of  visitors,  I  was  placed 
in  one  of  the  more  or  less  unhygienic  dependencies,  situated  in  the 
centre  of  the  town,  and  devoid  of  gardens,  etc.,  which  make  so 
much  difference  in  the  value  and  pleasantness  of  a  place  for  invalids. 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    VII.  4   H 


610 


DU   H,    C.    TAYLORS    EXPERIENCES   OF   A 


[JAN. 


One  soon  found,  however,  that  Orotava  had  many  advantages  over 
Las  Palmas, even  in  its  present  condition;  but  not  only  so,  its  pos- 
sibilities were  much  greater.  To  begin  with,  the  town  is  far 
smaller,  and  within  a  very  few  minutes'  walk  of  any  part  of  it  there 
is  a  fine  sea-beach  bounded  by  a  nice  level  road,  which  could  very 
easily  be  made  into  a  splendid  promenade.  Again,  though  the 
town  is  placed  on  a  low  peninsula  of  land  and  very  little  raised 
above  the  sea-level,  the  ground  rises  very  rapidly,  almost  pre- 
cipitously, at  the  back  of  the  town  to  a  sloping  plateau  with  an 
elevation  of  about  300  feet,  thus  affording  splendid  sites  for  the 
future  building  of  villas.  Here  the  new  hotel  company  have  already 
commenced  to  build  a  fine  hotel,  which,  it  is  hoped,  will  obviate 
many  of  the  disadvantages  of  position,  arrangement,  and  manage- 
ment so  bitterly  complained  of  by  many  visitors  during  last  season. 

Though  Orotava  is  situated  on  the  north  side  of  the  island,  it  does 
not  experience  the  cool  north-east  trade  winds  in  such  force  during 
the  winter  months  as  Las  Palmas,  for  the  island  of  Teneritfe  is  not 
then  so  directly  in  the  track  of  these  winds  as  that  of  Grand 
Canary,  though  it  has  the  advantage  of  experiencing  them  as  con- 
tinuously during  the  summer  months,  when  they  exercise  a  grateful 
and  cooling  influence  on  the  climate.  Vegetation  is  decidedly 
more  prolific  than  around  Las  Palmas — a  very  barren  place — thus 
rendering  the  country  far  more  beautiful  and  pleasant,  though 
indicating  a  rather  damper  climate.  The  rainfall  is,  however,  only 
about  14  inches  in  the  year,  and  the  ground  being  composed  of 
volcanic  scoriae  and  rock,  is  very  porous  and  quickly  dries. 

My  meteorological  observations  taken  at  Orotava  for  the  past 
season  were  as  follows  {vide  Table),  by  which  it  will  be  seen  that 
50°  F.  was  the  lowest  temperature  recorded,  and  that  the  mean 
temperature  of  the  five  winter  mouths,  62°"8  F.,  is  almost  identical 
with  the  mean  summer  temperature  of  London,  i.e.,  62°'3  F. 


Becord  of  Temperatibre  taken  at  Port  Orotava,  Winter  1887-8. 


Mean  for  month,   . 

November. 

Fahr. 

.     65-7 

December. 

Fahr. 

64-6 

January. 

Fahr. 

62-2 

February. 

Fahr. 

60-4 

March, 

Fahr. 

61-5 

Mean  maximum,    . 

.     71-6 

70-2 

67-8 

66-5 

67-5 

Mean  minimum,    . 

.     59-8 

59 

57-6 

54-4 

55-6 

Mean  range,      .     . 

.     11-8 

11-2 

11-2 

121 

11-9 

Highest  maximum, 

.    77 

821 

74-5 

73 

761 

Lowest  minimum, . 

.     53 

56 

50 

50 

53 

Approximate  amount  ) 
of  sunshine,  .     .     .  j 

Hours. 

180 

Hours. 

1791 

Hours. 

163 

Hours. 

234 

Rainy  days  (daylio 
only),    .... 

;ht)    _ 

3 

5 

8 

5 

^  Hot  (S.E.)  wind,  occasionally  experienced  from  Africa,  and  corresponding 
to  the  Leste  of  Madeira.    The  obsei-vations  for  November  were  taken  by  a  friend. 


1889.]  WINTER   IN    THE    CANARY   ISLANDS.  611 

Note. — Thermometers  with  full  northern  exposure,  no  Stevenson's 
screen,  which  probably  renders  the  result  rather  lower  than  if  one 
had  been  used. 

The  mortality  from  plithisis  is  small,  though  the  natives  are  by 
no  means  exempt;  and  the  death-rate  per  1000  at  Orotava  for  the 
following  years  was  as  follows :— 1875,  0-94;  1876,  047;  1877, 
1-0  ;  1878,  1-62  ;  and  in  1879, 1-41.  The  general  death-rate  varies 
from  about  14  to  22  per  1000. 

Before  closing,  I  cannot  refrain  from  adding  a  few  words  on 
Madeira.  Though  this  island  is  far  better  known  both  to  the 
profession  and  to  the  public  than  the  Canaries,  and  has  been  much 
frequented  by  invalids  for  the  last  forty  years,  yet  it  has  lately  to 
a  certain  extent  gone  out  of  fashion  since  the  rigorous  treatment 
of  phthisis  by  wintering  in  Alpine  regions  came  into  vogue.  The 
disadvantage  urged  against  the  climate  is  its  humidity,  which, 
however,  is  by  no  means  excessive,  the  relative  humidity  being 
almost  identical  with  that  of  Cannes  (which  Dr  Marcet  gives  as 
73  per  cent.),  though  undoubtedly  the  rainfall  and  number  of  rainy 
days  are  greater.  Madeira  has,  however,  no  mean  advantages  in 
other  respects, — firstly,  in  the  good  food  obtainable  (in  striking 
contrast  to  the  Canaries) ;  secondly,  in  the  entire  absence  of  dust ; 
thirdly,  in  the  hotel  comforts,  and  the  unusual  way  in  which  the 
proprietors  lay  themselves  out  to  meet  the  wants  and  requirements 
of  invalids.  Indeed,  it  is  very  rare  to  find  in  any  of  the  hotels  of 
the  many  health  resorts  of  the  Continent  (and  I  speak  from  expe- 
rience) such  consideration  and  attention  paid  to  the  invalid  as  is 
done  here.  It  has  suffered,  however,  in  the  past  from  the  position 
of  the  hotels,  for  I  feel  convinced,  if  they  had  been  more  judiciously 
placed  in  the  outskirts  of  the  town  (as,  for  instance,  the  excellent 
situation  of  Mr  Card  well's  new  hotel,  which  is  on  high  ground 
facing  the  sea,  with  ample  space  around  it,  so  that  the  bracing  sea 
breezes  are  constantly  felt),  so  many  complaints  of  the  climate 
being  enervating,  oppressive,  and  relaxing  would  never  have  been 
heard. 

Teneriffe  has  great  capabilities  for  a  health  resort  in  its  dry  and 
equable  climate,  but  labours  under  many  disadvantages  through  its 
lack  of  development,  which,  however,  are  mostly  removable  by 
time  and  good  management.  Madeira,  on  the  other  hand,  has 
scarcely  such  a  good  climate,  being  certainly  damper,  but  it  has 
at  present  the  advantages  pertaining  to  a  well-developed  health 
resort. 


612  MR  T.   ARTHUR   HELME   ON   THE  [jAN. 


v.— THE  PHYSIOLOGY  OF  THE  THIRD  STAGE  OF  LABOUR: 
A  CLINICAL  CONTRIBUTION. 

By  T.  Arthur  Helme,  M.B.,  Physician  to  the  Women's  Dispensary,  Edin- 
burgh ;  formerly  Buchanan  Scholar  and  Clinical  Assistant  in  the  Gyne- 
cological Department,  Royal  Infirmary,  Edinburgh. 

{Read  before  the  Edinburgh  Obstetrical  Society,  lUh  Nov.  1888.) 

The  following  account  of  a  labour,  which  I  have  the  honour  of 
presenting  to  the  Fellows  of  this  Society,  possesses  a  special 
interest,  inasmuch  as  its  facts  seem  to  have  a  clear  bearing  on 
the  now  much-debated  question  of  the  Separation  of  the  Placenta. 
In  regard  to  this  we  have  at  present  two  main  ideas,  the  one 
directly  opposed  to  the  other :  according  to  tliose  who  hold  by  the 
one,  the  placenta  is  separated  during  the  time  when  the  area  of 
the  uterine  wall  is  becoming  smaller;  while  according  to  those  who 
hold  by  the  other,  the  placenta  is  separated  during  the  time  when 
the  area  of  the  uterine  wall  is  becoming  larger.  The  following  case 
(in  addition  to  other  points  of  interest)  presented  an  almost 
unique  opportunity  for  observing  the  clinical  aspect  of  this 
question,  and  it  is  to  this  portion  of  the  history — dealing  with  the 
Third  Stage — that  I  w^ould  particularly  draw  attention. 

I  was  asked  by  Dr  M'Call,  to  whose  kindness  I  am  indebted  for 
the  following  particulars,  to  see  Mrs  T.,  aged  35,  an  viii.-para. 
Labour  had  set  in  early  in  the  day,  but  pains  continued  very 
slight  till  nearly  5  o'clock.  The  child  was  born  at  5.15 
P.M.,  the  doctor  arriving  immediately  thereafter.  Finding  the 
abdomen  still  of  large  size,  he  examined  the  patient,  and 
found  the  os  cervix  occupied  by  a  bag  of  membranes,  but 
no  part  of  a  foetus  was  palpable,  nor  were  any  heart-sounds 
audible  with  the  stethoscope.  At  7  o'clock,  as  pains  did  not 
return,  I  was  asked  to  see  the  patient.  On  examination  the 
following  condition  presented  itself: — Abdomen  immensely  dis- 
tended and  almost  globular,  the  superficial  veins  very  striking. 
The  size  of  the  abdomen  would  have  been  remarkable  even  in  an 
ordinary  single  pregnancy,  and  of  its  appearance  before  the 
expulsion  of  the  first  child  it  would  be  difficult  to  form  any 
conception.  On  palpation  the  walls  of  the  abdomen  were 
exceedingly  tense  and  elastic ;  the  uterus  could  not  be  recognised 
as  a  distinct  sac,  and  no  foetal  parts  could  be  felt  within ;  while 
on  percussion  a  fluid  thrill  was  most  markedly  given  as  one  is 
accustomed  to  feel  it  in  an  ovarian  cyst,  showing  the  extreme 
distension  and  thinness  of  the  uterine  wall.  Auscultation  revealed 
no  foetal  heart. 

Per  vaginam,  the  cervix  was  widely  dilated,  the  bag  of  mem- 
branes presenting;  on  pushing  this  upwards,  while  the  patient 
was  lying  on  her  back  or  side,  no  foetus  could  be  felt,  but  on 
placing  her  in  a  half-sitting  posture,  one  felt  a  small  hard  body, 


1889,]  PHYSIOLOGY   OF   THE  THIRD   STAGE   OF   LABOUR.  613 

resembling  a  knee,  fall  upon  the  examining  finger,  immediately 
receding  on  exercising  the  slightest  pressure  from  below.  There 
was  evidently  a  very  considerable  amount  of  liquor  amnii.  As 
two  hours  and  a  half  had  elapsed  since  the  birth  of  the  first  child 
(and  no  placenta  had  escaped),  I  ruptured  the  membranes,  and 
after  the  escape  of  a  large  quantity  of  fluid,  I  passed  my  hand 
away  up  into  the  uterus,  and  found  that,  situated  on  the  dorsum 
of  the  child  in  the  cervical  region  there  was  a  cystic  body,  very 
thin  walled,  and  about  the  size  of  a  large  orange,  evidently  a  spina 
bifida.  It  was  impossible  to  deliver  the  head  and  this  together 
safely,  and  during  its  passage  through  the  pelvis,  the  thin  cyst 
wall  ruptured.  The  cord,  in  which  no  pulsation  could  be  detected 
by  the  time  the  child  was  delivered,  was  ligatured  and  divided. 
(Two  ligatures  were  used,  and  the  cord  divided  between  them.) 
No  inspiration  was  made  by  the  child,  though  movements  of  the 
lips  occurred,  and  after  the  cord  had  been  cut,  a  few  feeble  trials 
were  attempted,  though  never  sufficiently  deep  to  draw  air  into  the 
chest. 

The  fundus  of  the  uterus  was  grasped  by  the  liand,  but  re- 
traction was  very  slight,  probably  owing  to  the  previous  over-dis- 
tension, and  contractions  were  almost  absent — in  fact,  the  uterus 
remained  in  a  flabby  condition,  feeling  like  a  piece  of  bowel 
rather  than  anything  else.  By  steady  kneading  and  friction 
(owing  to  the  now  laxness  of  the  abdominal  walls,  one  had  perfect 
control  over  the  uterus)  an  occasional  contraction  was  called  forth, 
the  uterus  making  a  fairly  respectable  imitation  cricket  or  prefer- 
ably football,  to  be  again  succeeded  by  a  rapid  relaxation  of  the 
uterine  wall,  so  that  the  fundus  reached  above  the  umbilicus, 
about  half-way  between  it  and  the  xiphoid  cartilage.  This  went 
on  for  half  an  hour  with  slight  hnemorrhage.  As  tlie  latter  seemed 
to  become  rather  freer,  eight  minims  of  ergotinin  were  injected 
hypodermically,  and  a  vaginal  douche  of  hot  water  administered, 
but  this  only  called  forth  a  weak  response  on  the  part  of  the 
uterus ;  the  haemorrhage,  however,  was  reduced.  On  passing  my 
fingers  into  the  interior  of  the  uterus,  both  placentae  were  found  to 
be  still  attached  to  the  uterine  wall;  1  therefore  grasped  the  uterus 
externally  between  my  hands,  and  gently  compressed  it;  this 
provoked  a  strong  contraction,  the  uterus  becoming  firm,  and  as 
it  was  felt  becoming  smaller  and  smaller,  the  patient  called  out 
that  something  was  coming  away — it  was  a  placenta  which  had 
separated  while  my  hands  were  grasping  the  uterus ;  it  escaped 
into  the  vagina,  whence  it  was  expressed,  being  born  edge  first,  and 
folded  as  Matthews  Duncan  has  described.  This  was  the  placenta 
belonging  to  the  child  last  born.  The  uterus  immediately  again 
became  flabby,  reaching  up  above  the  umbilicus;  and  now  bleeding 
had  become  more  active — instead  of  a  faint  dribbling  it  began  to 
trickle  away.  On  passing  the  hand  into  the  interior  of  the  uterus 
I  found  that  partial  separation  had  taken  place,  the  placenta  being 


614  Mil   T.   ARTHUR   IIELME   ON   THE  [jAN. 

detached  at  its  lower  extremity.  By  kneading  and  pressure  one 
or  two  very  faint  contractions  were  aroused,  followed  by  full 
relaxation,  tlie  uterus  extending  up  above  the  umbilicus,  and 
feeling  like  a  piece  of  bowel  in  which  the  blood  could  be  felt 
crackling.  I  decided  to  prevent  any  further  loss  of  blood  by 
removing  this  second  placenta  by  the  hand.  This  was  done 
without  "any  difficulty,  the  placenta  leaving  the  uterine  wall  easily 
and  cleanly :  the  points  that  struck  me  most  forcibly  being  the 
extreme  tenuity  of  the  uterine  wall — it  seemed  to  be  like  two  or 
three  sheets  of  writing  paper  between  the  fingers  of  the  two  hands 
— and  the  looseness  of  the  placental  attachment  to  the  uterine 
wall. 

I  have  reported  this  case  fully  because  of  its  not  uninteresting 
relation  to  the  important  subject  of  the  phenomena  of  the  Third 
Stage.  Of  late  this  subject  has  been  prominently  brought  under 
the  notice  of  this  Society  in  its  anatomical  and  purely  physio- 
lof^ical  aspects,  but  clinical  observations  are  much  needed,  for, 
although  anatomical  study  will,  and  must,  take  a  necessarily 
important  part  in  helping  to  build  up  the  foundation  of  its 
explanation,  it  is  to  clinical  study  that  the  chief  part  belongs ; 
with  it,  indeed,  lies  the  final  accepting  or  rejecting  of  the  results 
obtained  by  other  methods,  according  as  they  agree  or  disagree 
with  clinical  experience. 

Dr  Berry  Hart  has  lately  propounded  an  entirely  novel  view  of 
these  phenomena ;  he  suggests  that  the  separation  of  the  placenta 
is  brought  about,  not,  as  usually  supposed,  by  the  diminution  in 
area  of  the  uterine  wall,  but  by  an  increase,  i.e.,  the  placenta 
separates  during  relaxation  of  the  uterus,  not  during  its  contrac- 
tion. Hart's  words  are : — "  Placenta  and  membranes  separate 
when  there  is  a  disproportion  at  the  plane  of  separation  between 
their  area  and  their  site  of  attachment.  This  disproportion  is  only 
slight,  as  the  trabeculse  are  microscopic.  This  disproportion 
happens  during  the  Third  Stage  in  the  relaxation  following  a  pain, 
and^  therefore,  separation  occurs  after  the  pain.  The  gist  of  the 
view  advocated  is  that  the  placenta  separates  in  the  Third  Stage 
after  the  pains,  and  is  expelled,  when  separated,  by  the  pains."  ^ 

The  facts  of  the  case  above  related  bearing  on  this  problem  may 
be  thus  summarized : — 

1.  Here  is  a  uterus  at  the  conclusion  of  the  Second  Stage 
containing  two  placentae,  both  attached  to  the  uterine  wall. 

2.  Placenta  No.  1  is  that  belonging  to  the  first  child,  born  three 
and  a  half  hours  before  the  second  child.  The  first  child  breathed 
and  cried  loudly  before  its  cord  was  ligatured,  so  that  all  con- 
ditions were  fulfilled  to  make  this  placenta  what  Dr  Hart  calls 
"  practically  a  bloodless  structure."  On  Dr  Hart's  relaxation 
theory,  therefore,  this  placenta  is  favourably  placed  for  separa- 
tion. 

1  "  On  the  Third  Stage  of  Labour,"  Edin.  Med.  Joiirn.,  Oct.  1888. 


1889.]  PHYSIOLOGY   OF   THE   THIKD   STAGE   OF   LABOUR.  615 

3.  Placenta  No.  2  is  that  of  the  second  born  child.  This  child 
did  not  breathe  before  the  cord  was  tied,  so  that  the  placenta  was 
not  aspirated,  hence  its  foetal  half  is  not  a  "  bloodless  structure,"  and 
on  Hart's  theory  this  placenta  is  unfavourably  placed  for  separation. 

4.  While  contractions  and  retractions  were  only  slight,  relaxation 
was  extreme,  the  fundus  receding  to  a  point  above  the  umbilicus 
after  expulsion  of  the  second  child. 

Here,  then,  is  a  relaxed  uterus,  containing  on  the  one  hand 
Hart's  bloodless  placenta,  and  on  the  other  hand  a  bloodful 
placenta.  If  the  uterus  could  be  made  to  contract  and  relax,  we 
should  naturally  expect  the  aspirated  placenta  to  separate  first. 
But  what  really  happens  ?  In  the  first  place  neither  placenta 
is  separated  during  relaxation ;  and  afterwards  that  placenta  is 
the  first  to  separate  whose  foetal  blood  has  not  been  aspirated  ; 
while  the  other  placenta  remains  attached  to  the  uterus,  though 
its  blood  has  been  aspirated. 

But,  further,  as  to  the  time  and  method  of  separation.  The 
placenta  which  came  away  first  (namely,  that  belonging  to  the 
second  cliild),  \\as  sejMvated  not  during  relaxation,  hut  during  a  pain. 
During  the  relaxed  condition  of  the  uterus,  I  ascertained,  by  passing 
my  hand  into  the  uterus,  that  both  placentte  were  attached  (No.  1, 
the  larger,  over  the  posterior,  right,  and  upper  portion  of  the  uterus, 
extending  over  the  fundus ;  No.  2,  the  smaller,  to  the  left  and 
front  and  below),  and  after  one  or  two  slight  contractions,  brought 
about  by  kneading  and  friction,  with  subsequent  extreme  relaxa- 
tion. On  renewed  examination  I  again  found  hoth  placeiitoi  still 
attached  to  the  uterine  wall.  It  was  immediately  after  this  last 
examination  that  I  compressed  the  uterus  (gently,  not  violently), 
and  -was  relieved  to  feel  a  response,  the  uterus  becoming  firmer  or 
harder — in  fact,  contracting  well,  and  then  suddenly  becoming 
smaller,  a  placental  mass  being  extruded  with  its  lower  edge  first. 
There  was  no  doubt  at  all  that  this  placenta  No.  2  separated 
during  a  genuine  uterine  contraction,  brought  about  by  a  stimulus 
applied  externally.  It  was  not  artifically  driven  out,  nor  forcibly 
torn  away,  but  separated  naturally  during  a  uterine  pain. 

After  this  the  uterus  again  became  distended,  so  that  the 
fundus  came  to  be  at  a  higher  level  than  the  umbilicus,  and  yet 
this  extreme  relaxation  did  not  detach  the  remaining  placenta 
though  it  was  "  practically  bloodless." 

Stimulation  had  the  effect  of  setting  up  one  or  two  slight 
contractions,  but  neither  these  nor  the  subsequent  relaxations 
detached  the  placenta.  It  was  therefore  artificially  detached; 
separation  presented  no  difficulty ;  there  was  no  special  bleeding 
(in  fact,  circulation  seemed  to  have  almost  stopped  in  the  maternal 
as  well  as  foetal  part  of  placenta),  nor  were  there  any  points  of 
morbid  adhesion,  the  finger  passing  along  the  plane  of  separation 
between  the  layers  almost  as  easily  as  through  butter.  Its  com- 
plete non-separation  seemed  to  me  to  be  entirely  owing  to  want  of 


616  MR   T.   ARTHUR  HELME   ON   THE  [jAN. 

uterine   contractions.      The  points  then  that  these  observations 
sliow  are  that — 

1.  Of  the  two  placentae,  that  whose  foetal  blood  was  not  as- 
pirated was  separated  and  expelled,  while  the  placenta  whose 
foetal  blood  had  been  fully  aspirated  was  not  separated. 

2.  With  regard  to  the  placenta  spontaneously  detached,  its 
separation  occurred  during  a  pain,  alter  complete  relaxation  had 
failed  to  detach  it. 

3.  With  regard  to  the  placenta  artificially  detached,  complete 
relaxation  of  uterus  failed  to  detach  it,  and,  owing  to  the  non- 
occurrence of  contraction,  it  remained  unseparated. 

These  facts  may  be  shown  as  follows : — 


Non-aspirated  Placenta. 

Aspirated  Placenta. 

Was  spontaneously  detached. 

Relaxation  failed. 

Contraction  succeeded. 

Was  not  spontaneously  detached. 

Relaxation  failed. 
Contraction  separated  lower  bor- 
der and  then  was  absent. 

Appendix. 

The  question  may  be  raised.  Why  the  placenta  of  the  first  child 
did  not  separate  along  with  the  placenta  of  the  second  child,  since 
they  were  subjected  to  the  same  contraction  ?  It  seems  to  me  that 
there  were  three  factors  which  influenced  this — 

1.  The  Mass  in  the  Uterus. — When  both  placentae  were  present 
there  was  a  large  mass  on  which  the  weak  uterine  power  could 
act.  This  power  was  not  able  to  separate  both.  It  separated 
the  one  and  not  the  other,  because  of  2  and  3. 

2.  Tlie  Condition  of  the  Bloodvessels. — The  one  placenta  was 
emptied  of  blood,  and  the  other  full  of  blood.  As  the  uterus 
becomes  smaller,  a  placenta  full  of  blood  will  not  follow  the 
diminution  in  area  of  its  site  to  the  same  degree  as  a  placenta 
which  contained  little  or  no  blood,  and  so  will  come  to  be  stripped  of. 

3.  The  Relative  Positions  of  the  Two  Placentce. — That  situated 
lowermost  separated  first.  During  separation  it  has  been  noted 
that  the  placenta  in  some  cases  is  detached  first  at  its  lower 
margin,^  so  here  the  placenta  situated  lowermost  was  first  separated. 

Another  question  arises  as  to  whether  there  was  any  morbid 
adhesion  of  the  last  separated  placenta.  I  think  certainly  not, 
on  the  following  grounds: — 1.  No  adhesions  were  felt;  2.  The 
separated  placenta  had  a  normal  and  healthy  appearance ;  3.  The 
child  was  healthy,  and  born  at  full  time ;  4.  The  other  placenta 

1 "  The  Third  Stage  of  Labour  :  A  Criticism  of  papers  by  Cohn,  Champneys, 
and  Berry  Hart,"  by  A.  H.  F.  Barbour,  M.A.,  M.D.,  F.R.C.P.E.,  ^f?.  Med. 
Jour.,  August  1888. 


1889.]  PHYSIOLOGY   OF   THE   THIRD   STAGE   OF   LABOUR.  617 

was  healthy,  and  separated  of  itself,  and  what  reason  is  there  that 
this  uterus  should  develop  in  its  interior  a  healthy  and  an 
unhealthy  placenta  at  the  same  time  ?  5.  The  placenta  was 
partially  separated  at  its  lower  margin,  and  if  the  contractions 
had  been  powerful  enough  it  would  probably  have  been  entirely 
separated. 

But  the  essential  point  is  that  relaxation  failed  to  separate  both 
the  placentae,  so  that,  even  if  the  second  placenta  were  "adherent," 
the  fact  still  remains  that  relaxation  failed  to  detach  the  first. 


VL— NOTES  ON  REPORT  OF  THE  DEPARTMENTAL  COM- 
MITTEE APPOINTED  TO  INQUIRE  INTO  PLEURO-PNEU- 
MONIA  AND  TUBERCULOSIS  IN  THE  UNITED  KINGDOM. 

By  Dr  Peel  Ritchie,  Vice-Pres.  Med.-Chirurg.  Society,  Pres.  R.C.P.  Ed.,  etc., 

F.R.S.E. 

{Read  before  the  Medico- Chirurgical  Society  of  Edinburgh,  7th  November  1888.) 

In  submitting  to  your  consideration  the  following  notes  on  the 
Report  of  the  Departmental  Committee  appointed  to  Inquire  into 
Pleuro-Pueumonia  and  Taberculosis,  it  may  be  well,  first,  to  briefly 
recall  the  association  of  this  Society  with  this  most  important 
inquiry,  especially  as  no  reference  to  the  Society's  action  appears 
in  published  Transactions.  On  the  15th  of  February  1888,  Prin- 
cipal Thomas  Walley,  M.R.C.V.S.,  in  an  elaborate  paper  on  Animal 
Tuberculosis  in  relation  to  Consumption  in  Man,  directed  our 
attention  to  the  relation  existing  between  animal  and  human 
tuberculosis.  After  a  very  full  discussion  of  the  pathological  and 
scientific  aspects  of  the  subject,  I  moved  that,  as  a  practical 
result,  it  be  remitted  to  the  Council  to  take  steps  to  carry  out 
some  of  the  author's  suggestions,  by  approaching  by  memorial,  on 
the  one  hand  the  legislative  authorities,  and  on  the  other  the 
municipal,  for  improved  and  extended  legal  enactment  was  not 
only  necessary,  but  the  local  enforcement  of  such  powers  as  were 
already  possessed  called  for  more  rigorous  application.  Accord- 
ingly, a  memorial  in  the  following  terms  was  presented  by  the 
President  in  name  of  this  Society  to  the  Marquis  of  Lothian, 
Secretary  for  Scotland,  on  the  23rd  of  March  1888  : — 

"  My  Lord  Marquis, — The  Medico-Chirurgical  Society  of  Edinburgh  having 
had  the  subject  of  animal  tuberculosis  in  its  relation  to  man  under  con- 
sideration and  discussion  along  with  that  of  other  bovine  diseases  alleged  to  be 
prejudicial  to  the  safety  of  the  community,  would  most  respectfully  approach 
your  Lordship,  in  order  to  express  their  sense  of  the  serioiis  nature  and 
momentous  importance  of  these  matters.  The  Medico-Chirurgical  Society  is 
composed  of  the  medical  practitioners  of  Edinburgh,  as  well  as  of  other  non- 
resident medical  men,  and  numbers  among  its  members  many  who  are 
cognisant  not  only  of  the  evil  which  has  been  clearly  traced  to  these  sources, 
but   deeply  impressed  with  the   necessity  for  some   active   measures  being 

EDINBURGH   MED.   JOURN.,    VOL.  XXXIV. — NO.    VII.  4  I 


618  DK  PEEL   RITCHIE   ON  [jAN. 

adopted  for  their  prevention.  The  Society  would  therefore  earnestly  pray 
your  Lordship  to  use  your  influence  and  the  powers  with  which  you  are 
invested  to  bring  into  operation  the  statutes  and  enactments  of  the  Govern- 
ment towards  the  prevention  of  those  evils,  and,  if  necessary,  for  the 
introduction  of  additional  means  for  the  regulation  and  supervision  of  the 
whole  traffic  in  milk  and  in  butcher's  meat  supplied  to  the  inhabitants.  I 
have,  with  the  authority  of  the  Medico-Chirurgical  Society,  the  honour  to 
address  you,  my  Lord,  on  the  subject,  and  in  its  name  to  subscribe  myself, — 
Your  Lordship's  obedient,  humble  servant,  John  Smith,  President." 

On  receipt  of  his  Lordship's  reply  of  the  16th  April,  the 
Secretary,  Mr  Cathcart,  again  communicated  with  him  on  the 
20th.  the  Departmental  Committee  of  the  Privy  Council  had 
commenced  to  take  evidence  on  pleuro-pneumonia  and  tuberculosis 
on  the  17th  April. 

"Edinburgh,  20th  April  1888. 

"  My  Lord  Marquis, — I  have  the  honour  to  acknowledge,  by  instruction 
from  the  Council  of  the  Medico-Chirurgical  Society,  the  receipt  of  your 
Lordship's  communication  to  the  Society  through  their  President,  Dr  John 
Smith,  dated  16th  April  1888.  I  am  directed  to  inform  your  Lordship  that 
the  Council  of  the  Medico-Chirurgical  Society  beg  respectfully  to  urge,  that 
the  object  of  the  inquiry  on  bovine  tuberculosis  will  be  best  served  by  their 
sending  two  members  to  give  evidence  on  the  subject.  One  of  them,  Dr 
Henry  Littlejohn,  24  Royal  Circus,  Medical  Officer  of  Health  for  this  city, 
will  be  prepared  to  refer  specially  to  the  etiology  of  the  disease,  and  to  its 
presence  in  cattle  sent  for  slaughter  and  kept  in  dairies.  The  other,  Dr  R. 
Peel  Ritchie,  1  Melville  Crescent,  President  R.C.P.,  a  man  of  wide  clinical 
experience,  will  be  able  to  give  information  as  to  the  transmissibility  of  the 
disease  to  the  human  subject  from  the  lower  animals, — I  have  the  honour,  etc., 

Chas.  M.  Cathcart." 

To  this  a  reply,  of  date  24th  April,  in  the  following  terms  was 
received : — 

"  Sir, — I  am  directed  by  the  Marquis  of  Lothian  to  acknowledge  the  receipt 
of  your  letter  of  the  20th  inst.,  proposing  that  two  members  of  the  Medico- 
Chirurgical  Society  of  Edinburgh  should  be  nominated  to  give  evidence  before 
the  Committee  now  sitting  to  inquire  into  the  subject  of  contagious  pleuro- 
pneumonia of  cattle,  etc.  ;  and  I  am  to  acquaint  you  that  a  copy  of  your  com- 
munication has  been  laid  before  the  Privy  Council  for  the  information  of  the 
Committee, — I  am,  etc.,  B.  W.  Cochran  Patrick." 

In  due  course  the  following  letter  was  received  by  Mr  Cathcart 
from  Mr  Richard  Dawson  : — 

Agricultural  Department,  44  Parliament  Street,  London,  S.W. 

Pkivt  Council  Office.  April  26th,  1888. 

"  Dear  Sir, — Your  letter  of  April  20th  has  been  forwarded  by  the  Secretary 
for  Scotland  to  the  Privy  Council,  and  laid  before  the  Departmental  Committee 
on  Pleuro-Pneumonia  and  Tuberculosis.  I  am  desired  by  the  Committee  to 
thank  you  for  this  communication,  and  to  say  that  they  will  have  pleasure  in 
hearing  the  evidence  of  Dr  Henry  Littlejohn  and  Dr  R.  Peel  Ritchie.  The 
Committee  think  it  advisable  to  take  this  evidence  towards  the  termination  of 
the  inquiry,— I  am,  etc.  Richard  Dawson,  Secretary  to  the  Committee." 

After  my  perusal  of  the  foregoing  correspondence,  it  appeared 
to  me  to  be  necessary,  as  I  had  been  nominated  one  of  the  repre- 
sentatives of  the  Society,  seeing  it  was  the  views  of  the  Society  I 
was  to  state  rather  than  my  own  as  an  individual,  that  the  secretary 


1889.]  PLEURO-PNEUMONIA   AND   TUBERCULOSIS.  619 

should  intimate  to  the  Fellows — such  Fellows  as  were  thought  suit- 
able— that  it  was  considered  advisable, in  the  interests  of  the  Society, 
that  they  should  supply  me  with  the  facts,  so  far  as  they  were  at 
liberty  to  do  so,  which  tended  to  support  the  view  that  bovine 
tuberculosis  was  capable  of  being  transmitted  to  human  beings, 
either  by  the  milk  of  affected  animals,  or  by  the  consumption  of 
their  flesh,  for  the  experience  of  one  individual  at  this  early  stage 
of  this  inquiry  was  not  yet  sufficient ;  and,  also,  that  the  combined 
observation  of  many  was  therefore  the  more  necessary,  if  due  effect 
was  to  be  given  to  the  memorial  of  the  Society.  In  reply  to  this 
appeal,  I  regret  to  say  there  was  only  the  response,  that  those 
written  to  "  have  no  evidence  which  they  are  in  a  position  at 
present  to  have  brought  forward." 

On  17th  May  Mr  Oath  cart  intimated  he  had  received  a  letter 
from  Mr  Dawson  to  the  effect,  that  it  had  been  decided  to  summon 
your  representatives  to  give  evidence  on  29th  May.  Whilst 
informing  Mr  Catlicart  that  I  had  written  Mr  Dawson  that  I  was 
ready  to  attend  on  that  day,  I  requested  that  a  meeting  of  the 
Council  should  be  called  in  order  that  I  might  consult  as  to  the 
evidence  it  desired  to  bring  before  the  Departmental  Committee. 
I  submitted  the  views  I  proposed  giving  on  behalf  of  the  Society. 
They  received  the  general  approval  of  the  Council,  and  I  thereafter 
wrote  Mr  Dawson,  that  "  the  line  of  evidence  I  propose  to  submit 
to  the  Departmental  Committee  is,  1st,  The  reasons  wliich  led  the 
Society  to  address  the  Secretary  for  Scotland  upon  the  subject  of 
bovine  tuberculosis ;  2nd,  The  evidence  submitted  to  the  Society ; 
and,  3rd,  The  necessity  for  further  experimental  inquiry  being 
made  into  the  transmission  of  bovine  tuberculosis  to  man." 

At  the  meeting  of  Council  it  was  approved  that  the  points 
regarding — 1st,  the  state  of  cow-houses,  dairies,  and  milk  sliops, 
and  the  laws  concerning  tliem ;  2nd,  The  exposure  and  seizure  of 
diseased  meat  in  slaughter-houses  and  markets ;  3rd,  The  existing 
powers  in  dealing  with  diseased  meat  or  milk;  and,  4th,  The 
further  extension  of  these  powers  by  enactment  of  Privy  Council 
or  legislation — should  be  left  for  the  evidence  of  the  other  repre- 
sentative of  the  Society,  Dr  Littlejohn. 

It  is  not  necessary  that  I  should  further  allude  to  the  memorial 
to  the  municipal  authorities. 

Before  considering  the  Committee's  Eeport  as  a  whole,  it  may 
interest  you  to  learn  the  terms  and  nature  of  the  evidence  given 
by  your  representatives. 

As  my  evidence  expressed  the  views  of  the  Society,  it  was 
taken  first,  but  as  explanatory  of  the  absence  of  reference  to  the 
Contagious  Diseases  (Animals)  Act,  I  desire  to  mention  that  my 
evidence  was  taken  as  that  of  a  physician,  and  as  approaching  the 
subject  from  the  public  health  side ;  and  that,  as  expressed  by  one 
of  the  Committee,  Prof  Brown,  "  an  Order  emanating  from  the 
Privy  Council  under  the  Contagious  Diseases  (Animals)  Act,  must 
not  have  any  direct  reference  to  the  public  health,  but  must  refer 


620  DK   PEEL   KITGHIE   ON  [jAN. 

to  the  prevention  and  spreading  of  the  disease  amongst  the  lower 
animals."     It  was  left,  therefore,  to  Dr  Littlejohn  to  press  this  point. 
My  examination  commenced  by  the  Chairman  asking  as  to  the 
representations  made  by  the  Society  to  the  Secretary  of  State  for 
Scotland  upon  bovine  tuberculosis  and  the  reasons  for  doing  so. 
In  reply,  I  stated  the  facts  with  which  you  are  already  familiar, 
the  reading  of  the  paper  by  Principal  Walley,  the  discussion  that 
ensued,  in  the  course  of  which  it  was  evident  that  his  statements 
had  made  a  profound  impression,  and  a  motion  had  been  carried 
unanimously  that  the  Government  and  the  municipality  of  Edin- 
buigh  should  be  approached — the  latter  with  regard  to  the  stricter 
enforcement  of  legal  enactments  regarding  byres  and  dairies ;  the 
Government,  because  the  subject  was  one  concerning  which  there 
was  considerable  doubt  in  the  minds  of  many  at  present,  and  it 
could  be  better  examined  into  if  Government,  rather  than  private 
investigators  or  individual  members  of  the  profession,  were  to  take 
it  up.     I  was  then  asked  to  give  a  brief  summary  of  the  evidence 
brought  before  the  Society.     In  doing  so  I  took  the  opportunity, 
first  of  all,  on  account  of  the  very  great  difficulty  of  diagnosing 
tubercle  in  the  early  stages  in  cattle,  to  point  out  the  necessity  for 
skilled  inspectors.     I  then  spoke  of  the  bacillus  of  tubercle  as  the 
cause  of  the  disease,  and  showed  that  most  competent  authorities 
held  the  doctrine  that  the  tuberculosis  of  bovines  and  the  tuber- 
culosis of  the  human  subject  were  identical,  that  the  apparent 
differences  in  the  bacilli  were  accidental,  and  due  to  the  differences 
in  the  media  in  which  they  were  developed  and  the  rapidity  of 
their  growth.    We  held  that  the  identity  of  the  bacilli  being  proved 
showed  that,  if  there  was  not  a  probability  of  communication,  we 
nearly  all  agreed  there  was  a  very  great  possibility;  and  I  went  on  to 
say  that  the  contagiousness  of  tubercle  had  already  been  declared 
by   other   societies,   mentioning   especially    the   meetings  of   the 
National  Veterinary  Association  in  London  in  1883  and  in  Man- 
chester in  1884,  and  that  of  the  International  Medical  Congress  at 
Copenhagen  in  the  same  year.     I  further  showed  that  contagion 
was  possible  in  three  ways :  first,  by  the  ingestion  of  tuberculous 
meat,  of  wiiich,  however,  we  had  as  yet  no  proof;  second,  by  the 
milk  from  tuberculous  cows;  and,  third,  by  inoculation  from  sores 
to  sores — that  was  to  say,  from  sores  upon  the  udders  to  sores  upon 
the  hands  of  those  who  handled  them.     In  support  of  these  two 
latter  methods  I  gave  particulars  of  the  cases  which  Principal 
Walley   laid   before   the    Society,   in   which  consumption,   tabes 
raesenterica,  and  meningitis  occurred  in  persons  partaking  of  the 
milk  of  tuberculous  cows,  aud  one  in  which  a  boy  with  sores  on 
his  hands  was  infected  from  sores  on  the  udder.     I  also  spoke  of  the 
impression  made  on  members  by  Dr  Woodhead's  observations  on 
the  phthisical  death-rate  in  an  establishment  supplied  by  a  dairy  in 
which  he  and  Professor  M'Fadyean  found  evidence  of  tuberculosis  in 
the  udders  of  three  cows.     A  question  arises  as  to  whether  tubercle 
in  the  general  system  of  an  animal  is  sufficient  to  affect  the  milk. 


1889.]  PLEUKO-PNEUMONIA   AND   TUBERCULOSIS.  621 

or  is  it  only  in  cases  of  tubercular  udders  that  the  milk  is  danger- 
ous ?  Observation  points  clearly  at  present  to  the  latter  condition 
only.  I  then  narrated  two  cases  which  occurred  in  my  own 
practice  to  support  the  view  that  tubercle  might  be  conveyed 
by  cow's  milk  if  a  like  condition  occurred  in  the  human  subject. 
These  were  the  cases  of  two  mothers,  previously  healthy,  who  be- 
came affected  during  the  suckling  of  their  infants — the  one  with  her 
first,  the  other  with  her  third  child.     Tlie  infants,  when  respectively 

4  months  and  7  months,  died  of  tubercular  meningitis ;  and  the 
mother  in  one  instance  died  four  and  a  half,  and  in  the  other 
four  months  afterwards  of  pulmonary  phthisis.  The  grounds  on 
which  I  supposed  the  infants  were  infected  by  the  mothers'  and  not 
by  the  cow's  milk  on  which  they  were  latterly  fed  being  the  subse- 
quent death  of  the  mothers  from  tubercular  disease.  Both  mothers, 
previous  to  the  infants  becoming  apparently  affected,  suffered  from 
irritation  of  the  mammary  glands  ;  they  never  suppurated,  but 
there  was  nodular  inflammation  of  the  glands.  I  was  examined  at 
length  upon  these  cases.  I  next  stated  that  we  also  felt,  as  a 
Society,  that  the  frequency  of  tubercular  disease  in  infancy  re- 
quires explanation,  and  mentioned  that  in  Edinburgh  during  the 
last  ten  years  the   average   death-rate   from    tuberculosis   under 

5  years  of  age  has  been  6 "8  per  cent,  of  the  deaths — that  is  to  say, 
of  44,616  deaths  at  all  ages,  3054  occurred  under  5  years  of  age 
from  tuberculosis.  I  also  stated  we  have  been  in  the  habit  in  the 
past  of  putting  these  down  to  hereditary  influences.  I  here  gave 
in  a  table  prepared  for  me  by  Dr  Littlejohn,  showing  the  deaths, 
and  pointed  out  the  frequency  with  which  disease  of  the  glands 
of  the  abdomen  and  inflammation  of  the  brain  occur  in  young 
children.  I  handed  in  a  table,  prepared  from  a  larger  one 
of  Dr  James's,  showing  the  total  deaths  in  Scotland  from 
tabes  mesenterica  and  tubercular  meningitis  during  ten  years, 
1876-1885,  under  5  years  of  age,  prepared  from  the  Eegistrar- 
General  of  Scotland's  returns.  During  that  time  7415  deaths 
occurred  from  tabes  and  13,216  deaths  from  tubercular  menin- 
gitis ;  and  "  it  was  found  that,  with  the  exception  of  the  first 
three  months  at  the  respective  ages,  inflammation  of  the  head 
always  caused  the  larger  number  of  deaths."  I  continued, — 
"  Now,  it  occurs  to  myself  that  possibly  the  greater  number  of 
inflammations  of  the  brain  have  been  preceded  by  disease  of  the 
glands  of  the  abdomen.  One  point  is  this,  that  in  the  first  three 
months  the  tabes  is  in  a  larger  proportion,  but  at  all  other  periods 
between  the  three  months  and  five  years  of  age  tubercular  menin- 
gitis is  the  largest  number.  Tubercular  meningitis,  according  to 
the  return,  may  thus  be  regarded  as  one  of  infection  from  tuber- 
culous glands.  The  glands,  therefore,  possibly  may  have  become 
affected  from  the  milk  which  the  children  have  been  fed  on  (I 
am  merely  speaking  as  a  possibility) ;  and  the  secondary  disease, 
inflammation  of  the  brain,  may  have  thus  often  resulted."  In 
course  of  further  questioning  upon  this  head  I  observed, — "  Men- 


622  DK    PEEL    RITCHIE   ON  [jAN. 

ingitis  being  much  more  rapid  in  its  fatal  course,  presents  the  more 
urgent  and  formidable  symptoms,  and  to  it  is  assigned  the  cause 
of'  death ;  whilst  tlie  tabes,  being  less  evidently  active,  may  be 
overlooked,  or  not  mentioned,  in  the  certificate  of  death."  I  con- 
cluded this  part  of  my  evidence  by  stating  that, — "  So  little  is  the 
subject  known  amongst  medical  men  at  present,  that  I  interviewed, 
before  coming  up  to  tliis  Committee,  between  forty  and  fifty  of  our 
leading  medical  men  in  Edinburgh,  and,  with  the  exception  of  Dr 
Woodhead,  none  of  them  had  seen  a  case  in  a  human  subject  which 
they  could  say  resulted  from  bovine  tuberculosis.  They  had  in 
several  instances  had  suspicions  that  such  a  thing  might  have 
occurred  ;  they  nearly  all  agreed  as  to  the  possibility  of  its  occurring. 
Some  of  them  doubted  its  possibility  ;  but  they  were  all  unanimous 
in  this,  that  the  subject  was  one  of  such  great  importance  that  they 
thought  an  inquiry  on  the  part  of  the  Government  was  necessary 
to  allay  the  popuhir  mind  and  the  doubts  at  present  existing." 
I  gave  it  as  my  opinion  that  this  inquiry  should  consist  of 
experiments  and  investigation  into  the  modes  of  communication 
of  the  disease,  that  it  should  be  extensive  in  character,  and  con- 
ducted by  a  Board  which  should  not  confine  its  labours  to  one 
part  of  the  country.  As  to  the  causes,  I  thought  the  conditions  tlie 
cows  are  kept  in  lead  to  it,  and  referred  to  their  insanitary  state  in 
Edinburgh.  Tlie  want  of  exercise  in  stall-fed  cows  aided  in  pro- 
ducing a  state  of  health  favourable  to  development  of  tubercle. 
Artificial  feeding  had,  I  also  thought,  some  influence,  the  cows 
being  fed  on  milk-producing  foods  rather  than  upon  blood  and 
flesh  improvers.  In-and-in  breeding  might  act  by  predisposing  to 
hereditary  constitution. 

In  answer  to  questions  by  Prof.  Horsley,  I  said  the  Society  had 
not  considered  the  evidence  of  the  communication  of  the  disease 
from  a  husband  to  a  wife ;  that  though  the  disease  might  be  intro- 
duced by  inhalation,  we  thought  it  was  not  so  in  cattle.  Possibly 
the  cow  got  it  in  the  stall  or  from  the  insanitary  state  of  its 
surroundings.  Cows  were  apt  to  lick  what  had  passed  from 
the  mouth  of  another  affected  animal  if  it  had  dried  up  on 
the  stall  in  which  it  was,  and  in  that  way  the  bacilli  might 
be  introduced  into  the  cow's  system.  I  had  no  figures 
to  show  the  actual  connexion  between  diseased  milk  or  flesh 
and  tabes  mesenterica  and  meningitis,  but  that  it  was  on  these 
and  such  points  that  we  w^ere  at  present  so  much  in  need  of 
enlightenment,  and  that  it  would  be  highly  advisable  for  the 
general  sanitary  condition  of  the  nation  that  an  inquiry  into  them 
should  be  instituted;  that  we  desired, if  possible,  to  have  a  check  put 
on  the  way  in  M'hich  diseased  animals  at  present  are  exposed  for  sale, 
are  slaughtered,  and  are  treated,  and  so  strengthen  the  hands  of 
the  veterinary  inspectors  in  getting  these  animals  properly  looked 
after.  I  considered  that  a  thorough  and  regular  inspection  by  skilled 
men  was  necessary  to  prevent  the  spread  of  the  disease  among 
cattla  and  its  transmission  to  the  human  individual,  and  that  such 


1889.]  PLEUKO-PNEUMONIA  AND   TUBERCULOSIS.  623 

inspectors  would  require  special  training  in  the  use  of  the  micro- 
scope and  the  detection  of  the  bacilli. 

The  Chairman  and  Mr  Stirling  both  put  questions  as  to  the 
phthisical  and  ordinary  death-rates  in  Edinburgh  of  late  years,  to 
which  I  replied  that  tlie  ordinary  had  diminished,  and  it  was  not 
found  that  the  deaths  from  phthisis  were  increasing,  but  it  was 
one  of  our  difficulties  that  we  did  not  know  when  or  how  long  this 
condition  that  we  were  now  wanting  information  about  may  have 
been  continuing  or  going  on.  I  stated  further  that  the  diminution 
in  the  death-rate  was  largely  in  consequence  of  the  excellent 
sanitation  of  the  Medical  Officer  of  Health.  I  was  also  asked  as 
to  the  destruction  of  the  bacilli,  and  said  that  in  milk  properly 
boiled  the  bacilli  were  killed,  but  I  could  not  speak  with  certainty 
as  to  the  spores. 

Professor  Brown  then  took  up  the  questioning  with  inquiry  as 
to  my  views  as  to  skilled  inspectors,  but  I  referred  him  for  infor- 
mation regarding  those  now  engaged  at  this  work  to  Dr  Littlejohn, 
repeating  that  they  would  require  to  be  specially  trained  in  the 
use  of  the  microscope  and  the  methods  of  demonstrating  bacilli. 
My  examination  concluded  with  questions  by  the  Chairman 
whether  milk  should  not  be  supplied  from  country  dairies  under 
proper  medical  and  sanitary  conditions  rather  than  from  town 
dairies ;  but  I  held,  as  the  introduction  of  the  late  epidemic  of 
scarlet  fever  had  been  from  the  country,  that  I  did  not  see  why 
our  town  dairies  should  not  be  made  perfectly  capable  of  supplying 
good  milk. 

Dr  Littlejohn  was  then  called  and  examined.  After  preliminary 
questions  he  informed  the  Committee  that  in  Edinburgh  the 
carcase  of  an  animal  affected  with  tuberculosis  was  not  allowed  to 
be  sold  except  the  disease  was  limited,  the  glands  unaffected,  and 
the  flesh  on  section  sound ;  that  the  authorities  had  no  data  to 
prove  that  the  use  of  flesh  of  animals  so  affected  had  any  effect  on 
the  public  health  (but  this  was  a  matter  for  further  investigation 
and  experiment) ;  that  they  had  no  power  to  seize  tubercular 
animals  in  the  markets  or  cowsheds,  nor  of  preventing  the  milk 
from  such  animals  being  mixed  with  that  from  healthy  animals. 
They  had  powers  to  seize  diseased  meat,  but  they  wanted  more 
than  that — to  take  the  live  animal.  He  would  like  that  they 
should  have  similar  powers  to  those  which  he  believed  were 
enjoyed  in  England  and  Ireland,  so  that  their  inspectors  might 
take  any  animals  from  the  public  markets  which  exhibit  a  sus- 
picious appearance  of  emaciation,  summoning  the  veterinary  in- 
spectors of  the  corporation,  and  craving  powers  from  the  magistrates 
to  have  that  animal  destroyed.  He  thought  the  Greenock  people 
had  such  powers  under  a  clause  in  their  Act  of  1877.  He  was 
also  of  opinion  that  tuberculosis  should  be  included  in  the 
Contagious  Diseases  (Animals)  Act,  because  this  would  give  them 
power  to  prevent  the  milk  of  suspected  animals  being  mixed  with 
other  milk  or  sold  for  human  food,  and  would  take  from  local 


624  PLEURO-PNEUMONIA   AND   TUBERCULOSIS.  [JAN. 

authorities  the  excuse  that  they  had  no  power  in  dealing  with 
this  disease,  and  as  public  opinion  was  being  so  much  directed  to 
this  point,  it  would  compel  these  authorities  to  more  stringently 
enforce  the  Dairies,  Cowsheds,  and  Milk-shops  Order  than  they  do 
at  present.  He  was  under  the  impression  that  tuberculosis  was 
on  the  increase,  and  gave  figures  showing  that  in  Edinburgh  in 
1877,  51  carcases  out  of  29,665  total  cattle,  and  during  the  first  five 
months  of  1888,  46  carcases  out  of  10,756  were  condemned.  Com- 
pensation he  spoke  of  with  diffidence,  but  would  be  inclined  to  grant 
it  only  where  a  mistake  had  been  made.  He  considered  the 
disease  was  more  common  among  dairy  than  among  ordinary  farm 
stock,  but  could  not  say  with  certainty  that  tuberculosis  could 
be  communicated  from  the  bovine  animal  to  the  human  sub- 
ject. That  the  disease  was  more  common  among  dairy  stock  was 
due,  he  thought,  to  the  manner  in  which  their  town  dairies  were 
managed.  The  ventilation  was  usually  bad ;  everything  was  kept 
in  a  state  of  constant  damp ;  the  animals  tied  close  up  against  the 
wall  and  close  together,  without  provision  for  the  proper  cubic 
space,  and  never  moved  out  from  the  one  year's  end  to  the  other, 
until  they  were  taken  away  for  slaughter.  He  recommended 
notification,  but  thought  that,  having  regard  to  the  difficulty  of 
diagnosis,  a  man  should  not  be  punished  for  not  giving  notice.  He 
thought  it  desirable  that  milk  should  be  examined  by  the  microscope 
and  other  means,  and  would  make  the  examination  for  the  tubercle 
bacillus  a  part  of  the  ordinary  inspection  of  the  dairy.  He  did  not, 
however,  suggest  it  as  a  remedy,  unless  it  was  proved  to  his  satisfac- 
tion that  in  every  case  of  tuberculosis  they  could  detect  the  peculiar 
bacillus  in  the  milk,  which  he  strongly  doubted,  because,  as  far  as 
his  own  experience  had  gone,  he  had  only  found  it  in  cases  where 
the  udder  had  been  markedly  affected.  Asked  as  to  the  propor- 
tionate distribution  of  the  disease  in  the  bodies  of  animals,he  said  he 
had  chiefly  observed  it — first,  in  the  pleura  and  peritoneum;  second, 
the  liver ;  and  third,  the  glands  generally.  The  lungs  were  rarely 
affected,  the  animal  apparently  being  killed  before  they  became  so. 
He  had  never  observed  deposit  of  tubercle  in  the  muscle  of  a 
bovine  animal,  but  had  in  that  of  a  pig,  and  had  seen  it  also  in 
the  joints  and  bones,  but  usually  the  animals  were  killed  before 
the  disease  had  become  so  extensive.  He  had  no  evidence  of  the 
spread  of  the  disease  from  one  animal  to  another. 

The  remainder  of  Dr  Littlejohn's  examination  had  reference  to 
the  carrying  out  of  the  Milk-shops  Order,  the  temperature  neces- 
sary for  the  destruction  of  the  bacillus  of  tubercle,  the  status  and 
pay  of  the  inspectors,  the  necessity  for  public  abattoirs,  the  inspec- 
tion of  country  dairies  and  the  disposal  of  their  milk  to  middlemen, 
the  dairy  companies  in  England  and  Edinburgh,  and  their  special 
private  sanitary  arrangements.  The  water  supply  of  Edinburgh 
dairies  was  then  touched  on,  and  the  risk  from  its  not  being  satis- 
factory or  imperfect  in  country  dairies,  concluded  his  evidence. 

{To  he  continued.) 


1889.]       INAUGURAL  ADDKESS   TO   THE   ROYAL   MEDICAL   SOCIETY.   625 

VIL— INAUGURAL  ADDRESS  TO  THE  ROYAL  MEDICAL 

SOCIETY,  26th  October  1888. 

By  Professor  W.  S.  Greenfield,  M.D.,  F.R.C.P.  Lond.  and  Ed. 

Mr  Phesident  and  Gentlemen, — When  I  was  invited  to  deliver 
the  Inaugural  Address  on  this  occasion,  both  my  first  and  second 
thoughts  were  to  decline  the  honourable  but  arduous  task.  For  not 
only  did  I  feel  myself  unequal  to  it  at  the  best  of  times,  but  the  an- 
ticipation of  a  special  pressure  of  work  during  the  vacation  made 
it  certain  that  I  could  not  do  it  justice.  That  I  consented  was  due 
to  the  fact  that  I  felt  that  this  Society  had  a  right  to  command 
any  feeble  services  which  I  could  render,  having  conferred  upon  me 
what  I  esteem  as  one  of  the  greatest  honours  of  my  life,  that  of 
becoming  one  of  its  Honorary  Fellows — an  lionour  which,  so  far  as  I 
am  aware,  I  have  never  done  anything  either  to  deserve  or  to  repay. 

The  light  in  which  I  regard  this  Society  probably  differs  from 
that  in  which  it  is  viewed  by  most  of  you  ;  for  in  past  years  I 
dwelt  in  a  city  where  this  University  and  Medical  School  were  but 
little  known,  and  were  greatly  misconceived.  But  in  the  obscurity 
enshrouding  the  little  known,  and  so  far  as  known  much  repro- 
bated. Medical  School  of  the  North,  there  shone  out  one  bright 
particular  star,  one  redeeming  feature.  A  graduate  in  medicine  of 
tliis  University,  or  a  licentiate  of  the  Colleges,  whatever  distinction 
he  might  have  attained,  had  as  such  no  honour ;  but  a  man  who 
had  been  a  President  of  the  Royal  Medical  Society,  and  still  more 
a  Senior  President,  whatever  that  mysterious  distinction  might 
import,  was  regarded  as  of  necessity  a  man  of  mark,  and  as  one 
who  had  a  passport  to  fame.  This,  and  this  alone,  far  outweighed 
and  superseded  any  other  testimonial  in  competition  for  an  ap- 
pointment. It  is  easy,  then,  to  understand  how  deeply  I  felt  the 
honour  conferred  upon  me  by  this  Society.  Fate  had  for  ever 
debarred  me  from  the  possibility  of  becoming  a  president,  but  such 
alleviation  as  was  possible  you  afforded  me. 

The  enormous  prestige  and  world-wide  reputation  enjoyed  by 
this  Society  are  well  grounded.  When  one  glances  at  tlie  roll  of 
past  Presidents,  and  others  who  have  been  prominently  connected 
with  it,  one  cannot  but  be  struck  with  the  familiarity  of  the 
majority  of  the  names.  These  men  have  become  known  to  fame 
by  their  discoveries  or  their  writings,  and  few  have  failed  to  justify 
in  after  life  the  opinion  formed  of  them  by  their  fellow-students. 

This  Society  has  just  completed  the  150th  year  of  its  more 
definite  existence.  Its  reputation  has  become  matter  of  common 
notoriety.  Nowadays,  however,  antiquity  and  historical  reputation 
mean  little  or  nothing.  We  live  in  an  age  which  is  largely  de- 
structive in  effect,  though  constructive  in  intention.  Much  that  is 
worn  out  and  useless  is  destroyed,  but  much,  too,  which  can  never 
be  rebuilt  or  restored.     But  as  things  are  it  is  often  safest  to  say 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — KG.    VII.  4  K 


626        PROF.  W.  S.  GUEE^TFIELD'S  INAUGUR.VL  A.DDRESS  TO  THE      [jAN. 

little  about  antiquity,  lest  the  iconoclast's  hammer  sliould  be  upon 
us.  Nor  in  any  case  is  it  wise  or  safe  to  rely  on  the  past.  In  a 
Society  like  this  everything  depends  on  the  present.  We  must  ad- 
vance with  the  times  ;  or  the  times,  which  after  all  can  get  on  very 
well  without  us,  will  go  on  and  leave  us  behind.  Adaptation  to  new 
circumstances,  fresh  developments  to  meet  new  needs,  are  essential. 

I  am  not  without  fear  that  even  the  Students'  Union,  much  as 
we  desire  its  success,  may  for  a  time  have  a  prejudicial  effect  upon 
this  Society.  Not  that  it  will  at  all  take  its  place  as  a  centre  of 
thought  or  scientific  activity,  but  that  some  may  feel  that  they 
cannot  give  the  time  or  the  money  to  both  institutions  in  their 
functions  as  reading-rooms  or  social  resorts.  It  will,  then,  be 
necessary  for  this  Society  in  every  possible  way  to  increase  and 
maintain  all  the  advantages  for  study  and  research  which  it  affords, 
as  well  as  to  promote  its  more  special  work. 

But,  after  all,  what  constitutes  the  strength  of  a  Society  like 
this,  and  its  surest  ground  of  success,  lies  in  the  men  who  have 
composed  and  do  compose  it.  It  is  a  human,  and  therefore  a  living 
association,  bound  to  the  past  by  the  character  and  life  of  those 
who  have  lived  in  it,  and  to  the  present  by  the  friendship  and  co- 
operation of  living  members.  So  long,  therefore,  as  the  character 
and  ability  of  its  leading  members  are  such  as  they  have  been,  it 
caimot  fail.  Three  of  the  strongest  motive  forces  to  influence  the 
human  spirit  are  united  in  its  support — hero-worship,  co-operation, 
research.  Let  me  say  a  few  words  on  two  of  these — hero-worship 
and  research. 

It  may  seem  strange  to  you  that  I  should  put  hero-worship  first. 
It  is  so  historically,  and  I  believe  that  it  is  in  fact  one  of  the  most 
powerful  motive  forces  affecting  every  man's  life.  In  all  profes- 
sions and  sciences  this  is  true,  and  in  Medicine — the  most  human 
of  professions — this  most  human  tendency  is  seen  at  its  strongest ; 
and  I  believe  that,  if  rightly  directed  and  properly  restrained,  it  is 
one  of  the  most  powerful  influences  for  good. 

It  may  be  alleged  that  1  am  mistaken  as  to  its  frequency  and 
influence,  that  nowadays  every  one  thinks  and  investigates  for 
himself  independently,  and  that  the  maxim,  "  Nitlliits  in  verba 
magistri  jurare,"  is  firmly  ingrained  in  every  student  from  his 
youth  up.  It  may  be  perfectly  true  that  there  is  now  little 
nominal  respect  for  this  or  that  authority.  In  the  old  days  the 
pupils  of  every  noted  teacher  or  healer  spoke  of  him  as  their 
master,  and  were  proud  of  tlieir  connexion  with  him.  His  dicta 
were  quoted  and  regarded  with  superstitious  reverence.  Every 
one  knows  how  the  sayings  of  Hippocrates,  Aristotle,  Galen, 
Avicenna  and  Averroes,  Sydenham,  and  others,  were  followed  long 
after  their  death,  and  how  rival  schools  under  lesser  lights  waged 
terrible  battles  for  or  against  some  theory  of  disease  or  mode  of 
treatment. 

But  the  historian  of  the  future  will  find  in  this  present  age 
precisely  similar  facts,  so  little  does  human  nature  change.     He 


1889.]  ROYAL   MEDICAL   SOCIETY.  627 

will  tell  of  the  battles  between  the  schools  of  Virchow  and  of 
Cohnheim  ;  of  the  great  trio  of  heroes,  Pasteur,  Lister,  and  Koch  ; 
of  the  long  battle  waged  between  the  followers  and  opponents  of 
the  antiseptic  system,  and  of  its  ultimate  triumph.  Or,  going 
further  back  into  a  now  remote  period,  he  will  tell  of  the  struggle 
which  preceded  the  abandonment  of  bleeding  as  a  common  means 
of  cure,  of  the  introduction  of  anaesthetics,  and  of  the  discrimina- 
tion of  various  forms  of  continued  fevers.  And  in  every  case  there 
will  be  the  same  tale — the  leader  or  leaders  of  progress,  its 
opponents,  and  their  respective  followers.  It  is  the  law  of  Nature, 
men  must  be  bound  together  in  progress,  and  the  strongest  and 
tallest  will  lead,  and  be  acknowledged  as  leader. 

But  it  is  not  exactly  in  this  light  that  I  wish  to  speak  of  hero- 
worship  ;  nor  when  I  use  the  term  do  I  mean  that  blind  idolatry 
which  is  often  connoted  by  the  expression.  The  Darwin  cultus, 
for  instance,  which  consists  in  intense  admiration  of  his  great 
genius,  his  earnest,  patient,  scientific  investigations  in  the  midst  of 
suffering,  of  his  acuteness  in  observation,  his  skill  in  planning  and 
carrying  out  experiments,  and  his  honesty  and  modesty  in  regard 
to  his  work,  is  the  very  opposite  of  that  blind  adoration  which 
accepts  his  speculations  as  laws  of  the  universe,  and  his  tentative 
suggestions  as  infallible  dicta, 

I  believe  that  every  man  should  have  a  hero,  or  more  than  one. 
I  never  met  any  man  who  had  done  anything  considerable  in  life, 
and  who  was  himself  looked  up  to  as  a  leader,  who  did  not  (if  one 
had  the  opportunity  to  discover  it)  reveal  the  fact  that  he  had  at 
least  one  hero.  For  the  most  part  the  hero  was  some  one  who 
had,  by  direct  teaching  or  personal  example,  communicated  some- 
thing of  his  own  character  or  vitality.  But  I  have  known  one 
whose  hero  was  Hippocrates,  and  I  have  heard  of  another  in  whose 
gallery  John  Hunter  was  most  notably  enshrined. 

Now,  I  do  not  see  why  hero-worship  should  not  be  regulated  and 
cultivated  both  by  the  individual  and  the  society.  For  the  indi- 
vidual it  may  be  that  the  hero,  like  the  poet,  nasciiur,  non  fit. 
There  must  be  individual  adaptation  and  recognition.  And  on  this 
I  will  only  say,  be  sure  that  you  have  at  least  one  hero.  You  may, 
indeed,  have  several — one  for  your  personal  life,  another  for  your 
public  life,  and  yet  another  for  your  scientific  and  medical  life. 
And  as  the  medical  hero  is  especially  my  subject,  let  me  caution 
you  not  too  readily  to  take  your  professional  hero,  but  to  make  him 
first  the  subject  of  some  study.  Be  sure  that  he  is  taller  than 
yourself.  Let  him  be  large  enough  to  appear  life  size  to  you  when 
you  have  put  him  on  a  pedestal,  and  let  him  be  some  one  whom 
you  will  be  likely  to  be  able  to  follow  for  at  least  ten  years  of  your 
professional  life.  I  know,  indeed,  that  one  must  occasionally  revise 
one's  list.  0.  Wendell  Holmes  speaks  of  dropping  a  friend  over- 
board every  now  and  then  in  the  course  of  life,  to  see  how  fast  one 
is  progressing,  just  as  in  heaving  the  log  at  sea  ;  and  one  may  need 
to  drop  a  hero  in  the  same  way,  or  to  take  on  another.     The  best 


628        PliOF.  W.  S.  GREENFIELD'S  INAUGURAL  ADDRESS  TO  THE      [jAN. 

kind  of  leading  hero  is  one  who  combines  various  qualities,  whose 
character  and  life  are  an  example  and  a  stimulus,  whose  scientific 
energy  and  method  give  an  impetus  to  your  own,  and  whose 
achievements  make  him  respected  by  others  as  well  as  yourself. 

I  think  this  Society  would  do  well  to  cultivate  the  memory  of 
its  heroes.  You  have  here  not  merely  the  record  of  their  names, 
but  the  beginnings  of  their  work ;  you  can  trace  back  to  the  early 
germs  the  ideas  and  methods  of  work  which  were  fruitful  in  their 
after  life.  In  these  somewhat  forbidding  and  dull  looking  volumes 
of  Dissertations  you  will  find  the  piece  of  work  which,  perliaps, 
was  that  to  which  the  man  ever  after  looked  back  as  his  best, 
because  done  with  all  his  youthful  freshness  and  enthusiasm. 

I  have  often  thought  that  on  some  such  opportunity  as  this  I 
would  try  to  present  you  with  some  record  of  those  whom  I  have 
known  intimately,  but  who  have  now  passed  away,  who  were  in 
their  time  Presidents  of  this  Society ;  but  I  will  only  venture  to 
say  a  little  of  one  who  is  especially  worthy  of  record — Charles 
Murchison.  Murchison's  name  is,  indeed,  commemorated  by  his 
works  and  by  the  Scholarship  in  Clinical  Medicine  bearing  his  name, 
which  is  annually  awarded  alternately  in  Edinburgh  and  London. 
But,  by  some  strange  mischance,  no  record  of  Murchison's  life  and 
work  has  been  written  beyond  the  newspaper  notices  at  his  death, 
I  desire  to  do  no  more  than  to  lay  a  stone  upon  the  cairn  to  his 
memory,  all  the  more  as  I  find  that  his  connexion  with  this  Society 
is  but  little  recalled. 

Twenty  years  ago,  when  I  was  a  student  in  London,  there  were 
very  few  systematic  clinical  teachers  of  medicine  in  London,  and 
of  these  few  four  stood  out  prominently  in  the  estimation  of 
students  and  of  foreigners — Jenner,  Gull,  Murchison,  and  Wilson 
Fox.  The  teaching  methods  of  Jenner  were,  I  think,  the  result  of 
his  own  innate  genius  and  sagacity,  and  he  stood  then,  as  now, 
facile  princeps  amongst  his  compeers  as  a  physician.  Murchison 
and  Wilson  Fox  both  followed  to  a  large  extent  the  mode  of  sys- 
tematic observation  and  analysis  in  clinical  teaching  which  has  long 
been  followed  in  Continental,  and  especially  in  the  French  schools. 
Both  derived  it,  I  believe,  immediately  from  Edinburgh,  where  it 
had  especially  been  carried  out  by  Professor  Hughes  Bennett.  My 
revered  master  Wilson  Fox  was  for  a  year  Eesident  Physician  in 
the  Royal  Infirmary  under  Hughes  Bennett  at  the  time  of  the 
Crimean  War.  Wilson  Fox's  mode  of  teaching  was,  however, 
considerably  modified  by  Jenner's  influence ;  there  were  the  same 
touches  of  intuition,  of  personal  experience,  of  genius,  which  made 
Jenner's  ward  visits  impressive  for  a  lifetime. 

Murchison's  method  of  teaching  was  purely  logical  and  de- 
ductive, his  system  of  diagnosis  apparently  immutable,  and  governed 
by  the  strictest  laws.  At  first  there  was  to  me  something  un- 
pleasing  in  this  absolutely  dogmatic  method,  in  which  everything 
appeared  to  be  cut  and  dried.  Nor  was  I  for  a  long  time  at  all 
impressed  with  tlie  teacher.     There  was  a  coldness  and  a  some- 


1889.]  ROYAL   MEDICAL   SOCIETY.  629 

what  sarcastic  mode  of  address  which  tended  rather  to  repel  than 
to  attract,  and  it  was  in  spite  of  this  that  he  was  followed  and 
admired.  It  was  only  as  one  came  to  know  him  better  that  one 
saw  that  this  was  only  manner,  and  tliat  under  the  cold,  critical, 
logical  exterior  was  one  of  the  truest  liearts  that  ever  beat. 

Although  I  had  occasionally  as  a  student  attended  Murchison's 
cliniques  at  the  Middlesex  Hospital,  it  was  not  till  four  or  five 
years  later  at  St  Thomas's  Hospital,  when  I  was  Medical  Eegistrar, 
that  I  came  to  see  more  of  him.  My  first  close  contact  with  him 
arose  through  a  case  in  which  a  strong  difference  in  diagnosis 
happened  to  arise,  and  in  the  discussion  of  this  case  and  its  sequel 
I  learnt  both  Murchison's  tenacity  and  his  generosity.  From  that 
time  he  was  my  generous  and  constant  friend.  In  many  long  con- 
ferences with  him  afterwards,  I  soon  discovered  both  his  sagacity 
and  profundity  as  a  physician. 

No  man  whom  I  have  ever  known  united  such  keen  insight  and 
such  minute  accuracy  of  observation.  His  memory  for  cases  was 
astounding.  He  seemed  never  to  forget  any  noteworthy  case  he 
had  seen  ;  he  remembered  it,  too,  in  every  particular,  and  with  the 
most  vivid  clearness.  In  his  clinical  teaching  he  would  not  go  a 
step  beyond  the  point  to  which  he  could  lead  the  student.  Every 
possibility  must  be  minutely  balanced,  and  the  case  decided  on  the 
clear  laws  of  evidence.  True,  the  diagnosis  might  sometimes  be 
wrong,  and  his  insight  as  a  physician  might  lead  him  to  see  that 
it  was  probably  inaccurate ;  but  for  the  student  it  was  safest  and 
surest,  and  would  teach  him  to  diagnose  correctly  in  the  great 
majority  of  cases,  and  to  recognise  more  clearly  the  grounds  of 
error  in  diagnosis.  But  take  Murchison  outside  his  class,  and 
discuss  the  same  case.  No  longer  the  same  rigid  dogmatic  rules, 
but  case  after  case  bearing  upon  the  one  in  question,  a  mine  of 
wealth  of  clinical  observation  tempered  by  the  soundest  judgment. 
How  well  I  remember  the  last  of  those  talks  when,  a  day  or  two 
before  his  death,  I  met  him  in  the  corridor  at  the  end  of  his 
hospital  visit,  fagged,  depressed,  and  worn  out.  Some  question  on 
a  case  in  which  we  had  a  common  interest  arose,  and  for  nearly  an 
hour  he  stood  discussing  and  illustrating  it  with  other  cases  with  the 
greatest  animation,  forgetting  fatigue  in  the  intensity  of  thought. 

I  have  mentioned  as  one  of  Murchison's  characteristics  his  stead- 
fastness. If  he  was  outwardly  somewhat  cold,  he  was  clear  and 
transparent  and  truthful  as  the  day.  The  Aberdonian  tenacity  of 
character  which  led  him  to  hold  so  firmly  to  what  he  had  observed 
made  him  equally  certain  as  a  friend.  One  always  knew  that  one 
could  reckon  upon  his  friendship.  In  how  many  ways  he  helped 
me  I  never  could  tell,  for  he  never,  when  it  could  be  avoided,  let 
me  know  that  he  had  any  hand  in  it.  But  I  knew  enough  to  know 
that  he  never  lost  any  opportunity  of  helping  me  in  every  way  in 
his  power. 

But  I  fear  you  will  think  that  I  am  misusing  this  opportunity 
to  give  you  too  much  of  my  personal  experience,  although  I  know 


630        PKOF.  W.  S.  GKEENFIELD'S  INAUGUKAL  address  to  the      [JAN. 

not  how  otherwise  to  give  you  an  adequate  idea  of  the  man.     Let 
nie  hasten  to  tell  you  something  more  of  Murchison  as  a  student. 

Of  liis  student  life  I  know  but  little.  Many  of  his  fellow- 
students  and  friends  still  living  can,  if  they  will,  tell  of  it. 
Entering  the  Botany  Class  in  the  summer  of  1847  at  the  age  of 
17,  he  soon  acquired  a  character  as  an  enthusiastic  observer  and 
investigator,  and  gained  the  warm  friendship  of  Professor  Balfour, 
who  often  corresponded  with  him  afterwards  on  botanical  subjects. 
Apart  from  his  high  character  and  the  position  he  took  in  classes, 
he  was  known  chiefly  as  a  quiet  student,  always  studious,  always 
at  work  at  something.  Making  but  few  friends,  he  succeeded  in 
selecting  four  or  five  who  have  since  become  men  of  world-wide 
fame,  and  who  still  cherish  his  friendship  as  one  of  the  best  of 
their  lives.  In  1850  he  became  house-surgeon  to  Mr  Syme,  and 
in  1851  took  his  M.D.  degree,  gaining  a  gold  medal  for  his 
thesis  on  Tumours.  It  was  during  the  session  1850-51  that  he 
was  a  President  of  this  Society.^ 

His  first  paper  in  this  Society,  so  far  as  recorded,  was  read  on 
14th  December  1849  (vol.  iii.  p.  307),  and  was  on  the  Bed  Cor- 
puscles of  the  Blood.  The  second,  read  22nd  March  and  5th  April 
1850  (vol.  iii.  pp.  827  and  957),  is  a  most  elaborate  monograph  of 
134  pages,  on  the  Anatomy,  Physiology,  and  Pathology  of  the 
Spleen.  The  latter  affords  an  admirable  example  of  the  character 
of  Murchison's  mind  and  the  method  of  his  work.  It  is  practically 
a  thorough  examination  of  all  that  w^as  known  upon  the  subject 
until  within  a  short  period  before  it  was  written.  First  we  have 
an  admirable  bibliography,  arranged  chronologically,  going  down  to 
the  year  1832,  and  including  73  papers.  Then  an  exhaustive 
account,  largely  compiled,  of  course,  of  every  point  of  importance 
in  relation  to  the  anatomy,  the  pathology,  and  the  functions  of  the 
organ.  One  may  especially  notice  as  characteristic  the  enormous 
industry,  the  methodical  arrangement,  the  clearness  of  thought  and 
expression  on  every  point,  so  that  one  can  have  no  doubt  as  to  the 
writer's  meaning.  Then  one  is  struck  by  the  fact  that,  whilst 
every  authority  has  been  studied,  and  their  facts  brought  forward 
in  due  place  and  order,  each  has  been  weighed  and  judged.  And 
although  the  paper  is  largely  a  compilation,  there  are  few  points 
on  which  he  himself  had  not  by  dissections,  injections,  and  micro- 
scopical examination,  made  original  observations  and  formed  his 
own  judgment. 

The  same  qualities  were  apparent  in  a  more  highly  developed 
degree  in  his  later  work.  As  an  example  of  his  industry  and 
method,  the  record  of  every  case  which  was  under  his  care  at  the 
Fever  Hospital  was,  so  to  speak,  dissected,  and  every  symptom, 
its  order  and  time  of  appearance,  etc.,  was  recorded  by  himself  in  a 
most  elaborate  schedule,  systematically  arranged,  so  that  when 
one  had  any  unusual  complication  or  condition  in  a  fever  case,  one 

1  I  am  indebted  to  Dr  Dobie  of  Chester  for  much  valuable  information  upon 
Murchison's  early  life. 


1889.]  ROYAL  MEDICAL   SOCIETY.  631 

had  only  to  ask  Murcliison  if  he  liad  ever  seen  it,  and  he  could  at 
once  put  his  finger  upon  the  record.  No  one  who  has  not  at- 
tempted it  can  tell  what  labour  this  involves,  when  it  comes  to 
hundreds  of  cases  recorded  as  Murchison  did  them.  But  it  is 
largely  to  this  that  the  great  value  of  his  classical  work  on  Con- 
tinued Fevers  is  due.  Yet  in  this,  as  in  everything,  like  a  calm 
and  deep  lake,  so  pellucid  and  placid  was  his  mind,  that  you 
hardly  realized  the  depth  until  you  tried  to  fatliom  it. 

Of  Murchison's  later  career  in  London,  his  work,  his  life,  and 
his  sudden  deatli,  I  cannot  now  speak.  It  ought  to  be  done;  but 
it  should  be  done  by  some  one  who  knew  him  better.  Apart 
from  his  two  great  works  on  Continued  Fevers  and  on  Diseases 
of  the  Liver,  his  contributions  to  pathology  and  medical  litera- 
ture were  voluminous.  As  a  pioneer  in  investigation,  and  by 
the  encouragement  and  aid  he  gave  to  others,  he  gave  great 
impetus  both  to  pathology  and  medicine.  But  I  am  not  qualified 
for  the  task  of  recording  his  labours  or  the  ennobling  influence  of 
his  character  and  life.  The  record  should  be  written,  and  there 
are  friends  still  living  who  could  do  it.  Even  in  what  I  have 
said,  I  know  1  have  failed  to  do  him  justice,  perhaps  because  he 
was  never  my  hero,  only  a  kind  and  generous  friend.  But  in 
his  life  and  work  you  have  only  a  sample  of  the  many  heroes  of 
this  Society.  Their  early  work  is  not  only  of  intense  interest  as 
a  study,  but  of  value  as  a  stimulus  and  an  encouragement  to  your- 
selves.    Cherish,  then,  their  memory,  and  emulate  their  labours. 

[The  following  testimony,  coming  as  it  does  from  one  who  knew 
Murchison  intimately  throughout  the  greater  part  of  his  medical 
career,  will  carry  weight  far  beyond  any  words  of  mine.  Professor 
Gairdner,  in  a  letter  in  reply  to  a  request  for  any  additional  par- 
ticulars before  publishing  this  address,  wrote  as  follows,  and  has 
kindly  allowed  me  to  print  here  some  extracts  from  his  letter : — 

"  There  may  have  been  men  superior  to  him  in  genius  and  even 
in  dogged  laboriousness,  but  very  few  men  indeed  have  had  the 
combination  of  quick  and  clear  insight  on  the  one  hand,  and 
exhaustive  mastery  of  details  on  the  other,  that  was  in  him. 
This  quality  of  steadfastness  held  with  him  to  the  very  last, 
and  was  applied  to  his  own  case  as  much  as  to  the  cases  of 
other  people.  I  never  knew  any  one  to  equal  him  in  his 
power  of  reading  up  and  thinking  out  a  subject,  and  then 
pigeon-holing  everything  that  he  had  observed  and  read  and 
thought,  so  as  to  be  infallibly  in  its  right  place.  His  book  on 
Fevers  is  in  this  respect  absolutely  unrivalled,  and  having  been 
accustomed  to  use  it  as  a  handbook  off  and  on  ever  since  its  pub- 
lication, I  can  scarcely  remember  an  occasion  on  which  I  have 
referred  to  it  in  vain,  whether  I  agreed  with  him  or  not.  Even 
the  slight  variations  between  the  first  and  second  editions — at  ten 
years'  interval — show  the  same  minute  carefulness  and,  as  you 
have  justly  called  it,  steadfastness.     One  might  have  thought  that 


632        PROF.  \V.  S.  GIIEENFIELD'S  inaugural  address  to  the      [JAN. 

between  1863  and  1873  he  might  have  tired  of  tlie  subject  of 
Fever,  after  having  given  it  so  much  of  his  time,  which  was  then 
becoming  more  valuable  in  a  pecuniary  sense  ;  but  having  had  a 
good  deal  to  do  with  the  changes  of  opinion  going  on  during  that 
interval,  I  can  bear  testimony  that  there  is  not  a  change  (other- 
wise than  merely  verbal  or  clerical)  in  the  text  of  the  book  that  is 
not  significant ;  and  scarcely  a  point  at  which  changes  might  have 
been  made  at  which  tliey  have  not  been  made,  so  as  to  indicate 
the  movement  going  on  in  connexion  with  tlie  whole  subject. 
Some  of  these  minutiae  of  detail  will  be  brought  into  notice  in  a 
volume  I  have  in  the  press.  All  of  them  will  show  how  minutely 
and  steadfastly  he  did  his  work  up  to  the  very  last. 

"  Mrs  Murchison  sent  me,  some  time  after  his  death,  a  number 
of  details  about  his  own  illness  which  he  had  put  on  paper.  I  did 
not  consider  them  of  any  great  novelty  or  scientific  importance, 
otherwise  I  would  have  published  them  ere  now.  But  what  they 
do  show  is  that,  even  when  looking  illness  and  death  in  the  face, 
he  was  not  bereft  of  his  instinct  for  seeing  the  truth ;  and  the 
personal  bias  in  no  way  interfered  with  his  desire  that  everything 
should  be  placed  exactly  in  its  right  position,  in  estimating  the 
facts  with  respect  to  diagnosis  and  prognosis. 

"In  the  autumn  of  1872  he  came  down  to  Scotland  to  consult 
me  as  to  the  aortic  lesion  which  had  then  become  known  to  him 
as  certainly  existing ;  and  his  one  anxiety  was  as  to  whether  I 
ct)uld  throw  any  light  on  the  very  serious  issue,  How  long  he 
might  hope  to  live  ?  I  never  was  in  London  after  tliis  without 
seeing  him ;  and  only  a  short  time  before  his  death  he  told  me 
that  he  liad  got  through  his  winter  work  with  more  ease  than  he 
expected,  and  had  never  had  so  much  remunerative  work  to  do. 

"  You  will  find  some  allusions  to  this  in  a  few  remarks  made  by 
me,  and  printed  in  the  British  Medical  Journal,  August  2,  1879, 
p.  193."] 

Another  of  the  functions  of  this  Society  of  which  I  wish  to 
speak  is,  to  aid  and  encourage  research.  It  may  be  said  that  in 
the  modern  sense  in  which  the  term  'encouragement  of  research'  is 
often  used,  i.e.,  the  giving  of  money  in  aid  of  or  as  a  prize  for  research, 
this  Society  does  nothing.  But  I  hold,  and  I  am  sure  that  those 
who  have  seen  much  of  such  encouragement  will  agree  with  me, 
that  money  is  that  which  does  least  for  true  research  in  any  branch 
of  science.  Money  may  be  needed  for  apparatus  and  costly  ex- 
periments, or  for  leisure  and  independence,  but  it  rarely  supplies 
the  motive  force ;  indeed,  alone  it  is  inert. 

The  stimulus  to  research  comes  first  from  that  innate  longing  to 
discover  truth,  to  pry  into  the  secrets  of  existence,  which  is  as 
much  a  part  of  our  nature  as  love  or  wonder.  The  youngest  child 
is  endowed  with  it — in  varying  degree,  if  you  like,  but  it  is  there. 
Very  often  it  is  almost  entirely  suppressed  by  bad  education,  or 
by  other  ambitious  and  interests,  but  to  some  degree  it  lies  dormant 


1889.]  ROYAL   MEDICAL   SOCIETY.  633 

in  every  man ;  and  the  medical  man  who  is  devoid  of  it  is  a  lusus 
naturm.  In  many  men  it  is  so  strong  that  it  cannot  be  suppressed, 
it  will  out.     With  Browning's  Paracelsus  they  say, — 

"  I  cannot  feed  on  beauty  for  the  sake 
Of  beauty  only,  nor  can  drink  in  balm 
From  lovely  objects  for  their  lovelines.s  ; 
My  nature  cannot  lose  her  first  imprint ; 
I  still  must  hoard  and  heap  and  class  all  truths 
With  one  idterior  purpose  :  I  must  know  ! " 

Browning's  Paracelsus,  p.  95. 

ISTone  the  less  is  it  true  that  in  a  great  majority  of  men  it  needs  to  be 
elicited  or  excited,  and  in  nearly  all  to  be  trained  and  cultivated. 

What,  then,  are  the  factors  which  stimulate  investigation,  apart 
from  the  innate  desire  to  discover  and  know  ?  One  is  the  pre- 
sentation and  discussion  of  numerous  subjects  which  afford  points 
of  dispute  or  difficulty.  Another  is  the  opportunity  of  publica- 
tion, and  especially  of  publication  where  free  discussion  and  criti- 
cism are  possible.  Add  to  these  the  influence  of  example,  and  you 
have  a  very  large  part  of  the  factors  which  do  practically  stimulate 
research. 

But  a  word  more  as  to  money.  A  man  may  do  anything  for 
money.  But,  practicall}^,  unless  a  man  has  all  the  qualiticatioiis 
of  a  researcher,  and  has  already  mastered  his  methods  and  subject 
also  to  a  large  extent,  he  can  no  more  do  a  research  for  money 
than  the  average  man  could  compose  a  sonata ;  or  at  least  it  would 
be  of  equal  value.  I  know  that  examples  will  be  cited  to  the  con- 
trary. M.  Pasteur,  I  believe,  made  his  remarkable  investigation 
on  "  P(^brine,"  the  disease  of  silkworms,  under  the  promise  of  a 
large  reward.  But  any  one  who  knows  anything  of  Pasteur  will 
know  that  he  was  already  a  master  workman,  that  his  immense 
energy  and  patience  were  devoted  then,  as  always,  to  the  solution 
of  the  scientific  problem,  and  that  the  intensity  and  concentration 
of  his  work  in  that  research  cost  him  the  use  of  one  arm,  and 
nearly  cut  short  his  labours,  if  not  his  life  ;  and,  as  his  subsequent 
career  has  shown,  he  values  neither  life  nor  money,  except  as 
a  means  to  the  promotion  of  science  and  the  benefit  of  living 
beings.  Even  those  discoveries  which  have  been  the  most  profit- 
able as  means  of  making  money  have  rarely  been  utilized  for 
money  by  their  discoverers.  "  Sic  vos  non  vobis  mellificatis  apes," 
it  is  the  old  story. 

In  the  case  of  discoveries  in  relation  to  medical  science  it  is  not 
expected  or  desired  that  money  should  be  the  incentive;  and  where 
it  has  been,  the  supposed  discoveries  have  usually  proved  to  be 
fallacious  and  worthless.  On  the  other  hand,  it  is  sometimes 
thought  that  the  sole  intended  ohjed  of  medical  research  is  the 
benefit  of  humanity.  We  may,  if  we  please,  lay  this  flattering 
unction  to  our  bosoms,  but  it  is  not  strictly  true.  The  idea  may 
encourage  and  console  us,  but  the  stimulus  is  really  much  tlie 

EDINBURGH   MED.   JOURN.,    VOL.   XXXIV. — NO.    VII.  4  L 


634        PROF.  W.  S.  GREENFIELD'S  INAUGURAL  ADDRESS  TO  THE      [jAN. 

same  as  in  all  other  scientific  work.  I  do  not  believe  that  pure 
benevolence  would  suffice  to  sustain  any  discoverer.  The  longing 
to  know,  the  desire  of  power  over  tlie  forces  and  secrets  of  Nature 
these,  too,  must  co-operate  and  predominate. 

Amongst  the  functions  of  this  Society  in  the  promotion  of 
research  is  the  bringing  forward  of  subjects  which  demand  inquiry. 
We  are  not  independent  of  one  another  or  of  external  stimulus. 
Thought  is  free,  but  most  of  it,  if  not  all,  is  induced — a  secondary 
current.  Spontaneity  of  thought  is  rare,  some  would  say  impos- 
sible. How  few  men  can  pass,  say  one  wet  day,  in  a  solitary 
Alpine  hut,  alone,  without  feeling  unutterably  bored.  Even  the 
greatest  of  men,  with  many  years  of  experience  and  thought 
behind  them,  often  become  mentally  inert  and  insipid  under 
such  conditions.  I  remember  a  learned  bisliop,  one  of  the  greatest 
living  commentators,  who  was  detained  in  such  a  Init  during  a 
storm  of  two  or  three  hours,  alone.  His  sole  subject  of  thought 
and  reflection,  as  he  told  us,  was  found  in  a  scrap  of  paper 
with  a  highly  eccentric  and  truly  German  spelling-pronunciation 
of  the  word  "Jane"  which  he  found  in  the  hut.  Nor  is  such 
mental  inertia  a  rare  or  morbid  phenomenon.  It  is  one  of  the 
laws  of  the  mind.  I  know  that  it  has  been  said  that  genius  is  the 
faculty  of  lighting  one's  own  fire,  but  such  genius  is  rare.  Let  me 
give  you  a  little  of  my  own  experience.  Nothing  is  commoner 
than  to  have  inquiries  addressed  to  one  as  to  what  subject  one 
would  recommend  for  a  research.  The  usual  formula  is,  "  I  intend 
to  spend  a  year  in  scientific  work  either  here  or  abroad,  and  to 
work  up  a  thesis,  will  you  tell  me  a  good  subject  ?  "  Of  course  one 
tries,  and  first  one  inquires  as  to  any  special  proclivity  for  subject 
or  method  of  research.  "  Oh,  I  have  no  choice  whatever ;  anything 
you  like."  Then  one  makes  an  effort  to  discover  what  special 
capacity  or  training  is  possessed,  and  rarely  elicits  a  confession 
of  some  peculiar  gift.  And,  lastly,  one  suggests  various  subjects, 
and  offers  such  help  as  one  may  be  able  to  give.  Bat,  as  a  rule, 
it  ends  in  nothing.  The  subject  is  too  difficult  ov  too  long,  or  the 
material  is  not  at  hand ;  in  fact,  the  one  vital  spark  of  special 
interest  and  desire  is  wanting,  and  the  molehill  becomes  a  moun- 
tain. In  truth,  you  cannot  manufacture  a  research — it  is  a  living 
thing,  and  must  grow. 

Gentlemen,  far  be  it  from  me  to  ridicule  such  desire  for  research. 
I  only  point  out  what  is  and  what  is  not  possible,  the  right  and  the 
wrong  method.  What  I  usually  say  to  such  men  is, — "  Well,  if 
you  have  no  desire  to  investigate  :onything  in  particular,  come  and 
learn  methods  and  do  some  definite  piece  of  work,  for  which  I  will 
find  you  the  material  and  guidance."  Then,  if  a  man  has  any 
capacity  for  research,  he  will  mee^  his  subject  by  the  way,  and  fall 
in  love  with  it.  Matrimonial  agencies  are  as  little  productive  of 
successful  research  as  they  are  of  happy  marriages. 

In  this  Society  the  constant   presentation   and   discussion  of 


1889.]  EOYAL   MEDICAL   SOCIETY.  635 

various  topics  brings  before  the  members  a  succession  of  moot 
points,  of  obscure  problems,  some  one  of  which  must  either  strike 
the  curiosity  or  suggest  other  subjects  of  inquiry.  Even  the  spirit 
of  opposition  to  some  dogmatic  assertion  will  very  frequently  serve 
as  the  starting-point.  Indeed,  but  for  the  innate  spirit  of  contra- 
diction of  established  dicta,  I  know  not  how  medical  science  would 
progress  at  all. 

I  believe  it  to  be  also  a  most  valuable  training  to  be  compelled 
to  write  on  some  subject  selected  by  others.  We  never  know  how 
little  we  know,  even  of  a  common  subject,  until  we  begin  to  try 
to  present  our  knowledge  to  oliiers;  and  however  distasteful  or 
remote  the  subject  may  be,  it  is  not  lost  time.  When  a  man 
knows  a  subject  thoroughly,  and  has  written  all  he  knows,  he 
should  never  be  allowed  to  write  upon  it  again.  Some  of  the  worst 
student's  manuals  are  written  by  great  authorities  on  the  subjects 
of  which  they  treat. 

Again,  the  opportunity  of  publication,  especially  where  the 
woi'k  can  be  freely  discussed,  is  a  great  stimulus  to  research.  Eew 
men  would  go  on  working  unless  they  hoped  to  make  the  results 
of  their  work  known  to  others.  The  mere  acquisition  of  know- 
ledge for  one's  self  is  indeed  precious,  but  gold  is  useless  unless 
coined  and  spent,  and  even  the  miser  hopes  some  day  to  enjoy  his 
wealth.  True,  he  may  and  must  leave  his  wealth  to  others ;  but 
the  scientific  miser  has  little  such  prospect.  To  begin  with,  his 
knowledge  will  probably  not  be  current  or  usable  in  the  next 
generation  unless  it  is  circulated  in  this  ;  and  very  few  can  or  do 
succeed  in  putting  more  than  a  fraction  of  their  work  into  circula- 
tion. What  piles  of  manuscript,  what  stores  of  knowledge,  the 
fruits  of  long  years  of  patient  observation,  thought,  and  labour,  go 
to  the  dust  bin  or  wastepaper  merchant,  or  are  accumulated  to  turn 
yellow  and  grimy  with  age  and  dust,  after  the  death  of  any  man 
who  has  been  engaged  in  scientific  or  medical  research  !  Earely, 
indeed,  they  are  rescued  by  some  later  worker  or  bookworm,  and 
used  commonly  to  throw  as  dirt  at  some  fresh  and  independent 
discoverer.  Witness  the  Italian  opposition  to  Harvey.  Or,  rarely, 
a  man  may  be  his  own  resurrectionist,  like  a  distinguished  opponent 
of  Cohnheim's  discoveries  on  the  circulation.  Most  men  leave,  for 
lack  of  time  and  energy,  much  of  their  best  work  unpublished;  and 
the  best  of  all,  the  experience  and  judgment,  ripened  by  long  thought 
and  work,  die  with  them.  Now,  I  do  not  say  this  to  encourage 
hasty  or  premature  publication.  Young  men  are  often  advised 
to  publish  something  as  soon  as  they  can — to  bring  them 
into  notice.  Well,  practice  and  money  may  be  made  by  adver- 
tising ;  reputation  is  not,  and  it  may  be  ruined.  But  the  great 
advantage  of  publishing  your  ideas  in  a  Society  like  this  is  that  it 
is  free  of  all  suspicion  of  ulterior  object,  and  that  you  may  bring 
imperfect  and  tentative  observations  forward  to  the  light  of  sug- 
gestion and  criticism. 


636      PROF.  w.  s.  Greenfield's  inaugural  address  to  the    [jan. 

A  few  words  more,  gentlemen,  on  tlie  subject  of  research,  and  I 
Lave  done.  First,  every  man,  even  as  a  student,  should  have  some 
research  on  hand,  something  which  he  cultivates  and  speculates  and 
observes  upon.  It  will  stinmlate  all  other  work,  and  afford  relaxa- 
tion and  interest  outside  your  regular  routine  of  study — will,  indeed, 
introduce  scientific  spirit  and  method  into  study  of  every  kind. 

Let  your  subject  be  your  own,  one  which  conmiends  itself  to 
you  as  a  worthy  one,  and  as  one  at  wliich  you  can  and  will  do 
good  work.  As  to  its  results,  be  they  ever  so  small  or  indefinite 
as  bearing  upon  tlie  direct  healing  of  disease,  they  cannot  be  value- 
less as  a  training ;  and  if  the  work  is  good  and  the  results  new, 
they  must  be  of  a  value  which  can  only  be  discovered  afterwards. 
If  one  traces  the  progress  of  any  branch  of  science,  one  meets  with 
numberless  instances  of  a  minute  and  accurate  piece  of  observation 
or  investigation  wliich  has  been  the  germ  of  a  revolution.  Nature's 
locks  are  large  and  strong,  but  the  keyholes  often  exceeding  small, 
and  the  key  simple  enough  to  him  who  can  find  it. 

If  you  cannot  find  a  new  subject,  follow  some  leader,  and  master 
his  work  as  far  as  you  can.  You  will  find  problems  enough  to  occupy 
you  as  you  go  along,  and  when  you  reach  the  end  of  his  work  you 
can  still  go  on.  You  \vill  have  the  additional  stimulus  of  the 
human  elements  of  admiration,  of  example,  and  influence,  which 
are,  after  all,  the  greatest  living  forces.  Do  not  be  too  anxious  lest 
your  subject  should  be  one  which  some  one  else  has  already  worked 
out  or  is  engaged  upon.  It  is  almost  impossible  to  start  an  en- 
tirely new  and  independent  inquiry — 

"  While  you  thought  'twas  you  thinking  as  newly, 
As  Adam  still  wet  with  God's  dew, 
You  forgot  in  your  self-pride  that  truly 

The  whole  past  was  thinking  through  you." 

Heartsease  and  Rue,  Lowell,  p.  134. 

The  same  forces  which  are  working  upon  your  mind  are  active 
upon  others  ;  you  are  being  carried  forwards  by  the  stream  of 
tendency  of  thought  and  by  the  previous  labours  of  others,  and  so 
are  many  more.  You  may  become  topmost  on  the  crest  of  the 
wave,  but  you  may  chance  to  see  another  more  fortunate  or  better 
endowed  by  Xature  or  opportunity  above  you — 

'Tis  in  the  advance  of  individual  minds 

That  the  slow  crowd  should  ground  their  expectation 

Eventually  to  follow  ;  as  the  sea 

Waits  ages  in  its  bed  till  some  one  wave 

Out  of  the  multitudinous  mass,  extends 

The  empire  of  the  whole,  some  feet  perhaps, 

Over  the  strip  of  sand  which  could  confine 

Its  fellows  so  long  time  :  thenceforth  the  rest, 

Even  to  the  meanest,  hurry  in  at  once. 

And  so  much  is  clear  gained. 

That  is  the  law  of  scientific  progress.  But  the  majority  of  investi- 
gators form  the  "  multitudinous  mass." 


1889.]  KOYAL   xMEDICAL   SOCIETY.  637 

Nor,  I  think,  should  you  be  at  first  too  anxious  to  find  all  that 
has  been  written  upon  the  subject  you  select.  Literary  research  is 
indeed  most  important,  and  I  would  on  no  account  justify  its  neglect. 
You  must,  indeed,  study  the  works  of  leaders ;  and  the  habit  of 
thorough  study  and  comparison  of  the  A^itten  records  on  any 
subject  is  a  most  valuable  one.  But  there  is  nothing  which  more 
discourages  a  man,  especially  at  first,  when  he  is  seeking  direct 
contact  with  Nature,  than  to  be  sent  to  wander  amongst  the  tombs 
of  buried  researches.  In  many  cases  it  will  suffice,  if,  before  you 
give  your  work  to  the  world,  you  decently  exhume  them  and  set 
their  skulls,  properly  labelled,  in  decent  order  in  that  mortuary, 
or  rather  ossuary,  which  is  usually  known  as  a  bibliography.  1 
know  that  in  saying  this  I  run  counter  to  the  fashion  and  to  the 
strongly-rooted  beliefs  of  many  whom  I  respect;  but  I  can  tell 
you,  from  my  own  experience,  that  the  attempt  to  carry  out  their 
precepts  rigidly  may  and  does  act  as  an  almost  absolute  barrier 
to  publication.  I  was  educated  in  the  belief  that  it  was  one  of 
the  seven  deadly  sins  to  publish  until  one  had  gone  over  the  litera- 
ture of  the  subject,  and  seen  all  that  had  been  done  before.  Nor 
can  I,  in  spite  of  my  acquired  belief  that  it  is  a  venial  sin,  so  far 
overcome  my  training  or  quiet  my  distorted  conscience  as  to  do  it 
in  cold  blood.  On  the  other  hand,  when  one  is  occupied  in  ob- 
serving, investigating,  and  recording  one's  own  observations,  it 
becomes  more  and  more  impossible  to  do  the  work  of  a  gravedigger 
at  the  same  time.  Therefore  I  am  anxious  to  some  extent  to  free 
you  from  this  bondage  of  what  is,  in  great  measure,  mere  literary 
pedantry.  At  any  rate,  carry  on  your  direct  questioning  of  Nature 
side  by  side  with,  or  rather  in  advance  of  your  literary  work,  and 
let  this  serve  you  as  a  guide  and  stimulus  and  not  as  a  chain. 
But  do  not  claim  priority  of  discovery  until  you  are  sure  that 
no  one  has  preceded  you,  and  for  this  you  must  exhaust  the 
records. 

Yet  another  caution  as  to  the  spirit  of  your  work.  Be  content 
to  go  by  degrees,  and  if  need  be  slowly.  Scientific  research  is 
much  like  Alpine  climbing.  You  see  before  you  a  summit  which 
leads  to  your  ultimate  destination,  and  with  slow  and  steady  steps 
you  push  on  till  you  reach  it.  Then  yet  another  appears,  entirely 
concealing  your  peak,  and  this  surmounted,  others  come,  each  of 
which  must,  still  with  painful  toil,  be  attained ;  and  it  may  be 
that  after  all  the  day  is  too  short,  and  you  find  the  night  fall  with 
the  snowy  peaks  still  far  above  you.  But  you  have  so  far  dis- 
covered the  road,  and  even  if  you  do  not  succeed,  others  will  come, 
and  guided  by  your  tracks  will  get  higher  and  higher.  Wait  a 
year  or  two,  and  where  you  had  only  marshy  swamps  or  dense 
thicket  there  will  be  a  carriage  road  ;  where  you  had  loose 
boulders  or  slippery  moraine,  there  shall  be  a  good  beaten  track 
with  steps  here  and  there  ;  and  it  may  be,  that  if  your  mountain  is 
a  very  special  one,  it  shall   be    favoured  with  a  railway  and  a 


638      INAL'GUltAL   ADDKESS   TO    THE   llOYAL   MEDICAL   SOCIETY.    [jAN. 

hydraulic  elevator.  But  you  have,  at  least,  made  the  ascent  pos- 
sible, and  the  track  is  certain,  easy,  passable  for  all. 

Nowadays,  however,  many  men  prefer  to  do  their  scientific  climb- 
ing in  a  balloon.  They  sail  away,  inliated  with  gas,  and  come  back, 
if  at  all,  with  wonderful  tales  of  their  discoveries  and  of  the  peaks 
they  have  visited.  But,  alas  !  seen  from  a  balloon,  many  peaks  are 
alike,  and  one  cannot  verify  their  observations,  still  less  follow 
them  and  make  a  sure  path  for  following  wayfarers.  Besides  which, 
balloons  have  an  unfortunate  tendency  to  be  carried  hither  and 
thither  or  lost  in  the  clouds,  not  to  mention  the  danger  of  burst- 
ing ;  and,  in  fact,  every  patli  of  scientific  research  nowadays,  and 
most  notably  bacteriological  research,  is  strewn  with  the  carcases 
of  rash  explorers  or  exploded  discoveries,  whose  remains  encumber 
the  way  and  make  progress  difficult. 

Gentlemen,  I  fear  these  discursive  remarks  may  have  been 
tedious,  that  you  may  think  I  have  been  too  much  in  the  vein  of 
Polonius,  as  well  as  speaking  too  much  of  my  own  experience.  If 
so,  I  pray  you  forgive  me. 

It  would,  indeed,  have  been  easier  to  take  some  more  concrete 
subject  in  medical  science  and  to  have  dwelt  upon  it.  But  it 
seemed  more  fitting  to  say  what  I  could  of  the  advantages  of  this 
Society.  And  if  so  much  of  good  appears  to  one  who  is  doomed  to 
be  and  to  have  been  to  so  large  an  extent  an  outsider,  what  may 
not  you  expect  to  enjoy  in  the  reality  if  you  join  this  Society.  I 
envy  you  the  opportunity  of  actually  linking  your  names  and  your 
labours  with  those  who  have  been  your  predecessors.  If  I  were  a 
student  again,  I  should  esteem  it  my  greatest  privilege  ;  and  as  I 
cannot  be,  let  me  promise  that,  so  far  as  I  can  in  any  way  benefit 
this  Society,  I  shall  reckon  it  an  honour  to  do  so. 


iPfftt  ^ccouQ. 


EEVIEWS. 

The  Principles  of  Cancer  and  Tumour  Formation.  By  W.  Roger 
Williams,  F.R.C.S.,  Surgical  Registrar  to  the  Middlesex 
Hospitah     London  :  John  Bale  &  Sons  :  1888. 

Few  subjects  have  more  occupied  the  minds  of  pathologists  than 
that  with  which  this  monograph  deals,  and  any  new  light  or  fresh 
thought  on  it  is  welcome  at  the  present  moment.  The  author 
begins  with  a  chapter  on  growth  and  another  on  reproduction.  In 
the  latter  is  found  tiie  key-note  of  the  writer's  contention  ;  it  is 
that  "  in  the  higher  organisms  certain  cells  never  attain  a  high 
degree  of  development,  they  remain  in  a  lowly  organized  condition, 
and  serve,  accordingly  as  tiiey  are  more  or  less  unspecialized,  either 
as  germs  for  reproducing  the  entire  individual,  or  for  forming  and 


1889.]       THE  PRINCIPLES  OF  CANCER  AND  TUMOUR  FORMATION.  639 

maiutainintr  the  various  tissues  and  organs.  Such  cells  are  found 
in  all  growing  parts,  they  are  the  only  real  cancer  and  tumour 
germs.'''' 

Tlie  third  chapter  is  a  valuable  contribution  to  the  study  of  the 
evolution  of  vegetable  neoplasms,  and  the  comparative  light  it  throws 
on  animal  neoplasms  is  of  much  importance  and  interest.  Here,  as 
well  as  in  the  subsequent  chapter  on  the  evolution  of  animal 
neoplasms,  the  contention  is  that  "  the  local  changes  are  modelled 
after  the  process  of  normal  growth,  and  that  both  are  subject  to 
the  same  laws."  The  author  rather  tends  to  over-estimate  his  own 
statement  of  this  law.  It  is  doubtless  true  that  new  growths, 
especially  the  malignant  new  growths,  were  in  the  past  looked  upon 
as  apart  from  the  ordinary  processes  of  growth  and  reproduction, 
and  were  even  regarded  by  some  as  parasitic  in  character;  but 
this  surely  belongs  to  the  past,  and  has  long  ceased  to  occupy  a 
place  in  the  teaching  of  pathology.  That  being  so,  and  as  Virchow's 
aphorism,  omnis  cellida  e  celluld,  still  dominates  pathology,  the 
author's  contention  so  far  is  a  truism. 

Let  us  look,  however,  at  his  chapter  on  the  evolution  of  animal 
neoplasms.  Malignant  growths  have  "  the  power  of  reproducing 
themselves  locally  after  removal  or  in  distant  parts,  whilst  others 
have  no  such  infective  properties,"  and  he  denies  that  this  implies 
specific  difference.  He  is  right  if  he  means  that  in  both  cells  arise 
from  pre-existing  cells;  but  is  there  anything  gained  save  novelty 
of  expression,  an.l  the  degree  of  pleasure  which  this  always  brings, 
by  saying  that  in  the  one  case  the  "emancipation"  of  the  cell  is 
more  complete  than  in  the  other?  "We  may  be  ready  to  accept 
this  term,  but  the  question  that  remains  is  only  a  paraphrase  of  the 
old  one.  What  makes  the  emancipation  in  the  one  case  more 
complete  than  in  the  other?  When  that  is  answered,  the  conun- 
drum of  malignancy  is  solved.  Nor  do  we  seem  to  get  nearer  the 
goal  by  the  statement  that  "malignancy  then  depends  upon  the 
indefinitely  sustained  activity  of  lowly  organized  cells,  which  grow 
and  multiply  indefinitely  without  ever  reaching  a  high  grade  of 
organization."  The  accuracy  even  of  the  assertion  might  be  called 
in  question,  for  it  can  hardly  be  granted  that  the  cells  of  a  skin 
epithelioma  or  of  a  malignant  adenoma  of  the  stomach  are  all  to  be 
regarded  as  lowly  organized  cells.  True  it  is  that  the  malignancy 
is  characterized  by  an  indefinitely  sustained  activity,  but  the  fore- 
going definition  hardly  helps  towards  the  elucidation  of  its  cause. 
The  author  objects  to  the  view  of  Creighton  and  others  that  the 
neoplastic  cells  infect  adjacent  cells  and  excite  in  them  morbid 
action  similar  to  their  own.  This  is  not  the  ))lace  to  examine  this 
question  on  its  merits,  but  the  author  says,  "as  it  is  opposed  to 
biological  principles,  and  without  parallel  elsewhere  in  organic 
morphology,  it  may,  I  think,  be  discarded;"  and  yet  he  says,  "  we 
may  attribute  the  genesis  of  all  neoplasms  to  excessive  activity  of 
certain  lowly  organized  cells  of  the  part  determined  by  local  excess 


640  PRINCIPLES  OF  CANCER  AND  TUMOUR  FORMATION,  ETC.       [jAN. 

of  imtritlon,  tlie  result  of  intrinsic  or  extrinsic  stimuli."  Is  it  then 
opposed  to  all  biological  principles  that  the  neoplastic  cells  contain 
the  special  stimulus,  and  that  it  acts  upon  the  other  tissues  of  the 
part  ? 

One  of  the  most  striking  features  in  tumour  formation  is  the 
reversion  to  embryonic  activity,  and  it  has  been  stated  by  others; 
but  while  it  gives  us  clearer  definition  more  can  hardly  be  claimed 
for  it. 

The  closing  chapter  is  devoted  to  etiology,  and  is  distinctly  the 
least  satisfactory,  and  the  monograph  would  not  iiavc  lost  much 
had  it  been  omitted. 

While  it  has  been  necessary  to  examine  as  critically  as  we  have 
done  the  leading  doctrines  in  tliis  monograph,  it  is  necessary  at  the 
same  time  to  state  that  we  consider  it  a  contribution  of  value  to 
the  discussion  of  a  subject  which  is  again  arresting  the  serious 
efforts  of  workers.  Because  of  this  very  fact,  however,  it  is  all  the 
more  necessary  to  closely  scrutinize  the  work  that  is  done,  but  all 
iionest  and  able  work  will  contribute  its  share  to  the  desired  result, 
and  this  monograph  may  certainly  be  allowed  this  rank." 


Cancer  de  la  Vessie.     Par  Ch.  FerS  (Prix  Civiale  1880).     Paris  : 
A.  Delahaze  &  E.  Lecrosnier:  1881. 

A  PUBLICATION  of  the  Progres  MMical,  extending  to  nearly  150 
pages,  and  containing  apparently  everything  that  has  been  written 
on  the  subject,  even  in  this  country.  M.  Fer^  describes  a  number 
of  preparations  from  the  Civiale  Museum,  gives  some  interesting 
cases  from  the  practice  of  M.  Guyon,  but  mainly  deals  with  the 
pathology  of  the  various  cancerous  affections  met  with  in  the 
bladder. 

The  work,  as  will  be  seen  from  the  titlepage,  was  selected  as 
worthy  of  the  Civiale  prize  in  1880.  It  will  make  a  valuable  book 
of  reference  on  the  subject. 


A  Manual  of  General  Patliology  designed  as  an  Introduction  to  the 
Practice  of  Medicine.  By  Joseph  Frank  Payne,  M.D.  Oxon., 
F.R.C.P.,  Physician  and  Joint-Lecturer  on  Pathological  Anatomy 
at  St  Thomas's  Hospital,  etc.,  etc.  With  150  Illustrations. 
London  :  Smith,  Elder,  &  Co. :  1888. 

We  welcome  this  book  as  one  which,  it  may  be  anticipated,  will 
do  not  a  little  to  mould  the  teaching  of  pathology  in  the  near  future, 
when  the  importance  of  the  subject  has  been  officially  recognised 
by  the  various  examining  bodies  in  the  Kingdom,  and  when,  as  a 
result,  the  teaching  will  be  more  methodical  and  more  satisfactory 
than  it  is  at  present  in  most  British  schools  outside  Scotland, 

The  plan  of  the  book  is  simple  and  rational,  and  in  accord  witii 
the  recent  revolutions  which  have  taken  place  in  our  views  of 
disease.     It  is  divided  into  two  large  sections:  the  first  dealing 


1889.]  A   MANUAL   OF   GENERAL   PATHOLOGY,   ETC.  641 

with  the  Processes  of  Disease,  the  second  with  the  Causes  of 
Disease.  The  former  opens  with  chapters' on  disturbances  of  tlie 
circulation,  goes  on  to  inflammation  and  fever,  and  then  to  degenera- 
tions. After  this,  a  chapter  is  devoted  to  the  laws  of  new  growths 
in  general,  and  the  succeeding  chapters  deal  with  tumours  or  new 
growths  ;  while  the  section  ends  with  four  chapters  on  the  varia- 
tions in  the  blood.  This  section  contains  nothing  specially  worthy 
of  note,  but  all  the  chapters  contain  the  latest  knowledge  or  specula- 
tions on  the  subjects  with  which  they  deal.  It  is  in  the  second 
part  that  the  freshness  and  originality  of  the  design  are  specially 
displayed.  As  indicating  the  range  of  subjects  treated  and  grouped 
under  the  causes  of  disease  may  be  mentioned  mechanical  and 
physical  injuries,  the  action  of  poisons,  dealing  with  animal,  septic, 
cadaveric,  and  specific  morbid  poisons,  and  acute  specific  fevers. 
Then  are  taken  up  parasites,  animal  and  vegetable.  Under  the 
latter,  he  deals  at  length  with  micro-organisms,  and  the  value  of  the 
book  is  enhanced  by  an  appendix  containing  directions  for  the 
examination  of  tissues  and  fluids  for  these. 

The  foregoing  gives  but  an  insufficient  indication  of  the  work ; 
to  appreciate  its  merits  it  requires  to  be  read.  Every  chapter  is  so 
well  done,  and  so  bears  the  mark  of  being  the  product  of  mature 
thought  and  extensive  acquaintance  with  diseased  processes,  that 
we  forbear  singling  out  any  for  special  commendation  or  foi  special 
criticism.  After  its  perusal  we  had  but  one  regret,  and  that  is,  that 
the  author  had  not  promised  to  give  us  a  volume  on  special  patho- 
logy in  addition ;  this,  however,  is  not  to  be  so  much  regretted, 
seeing  we  already  possess  some  excellent  books  dealing  witii 
the  morbid  anatomy  of  the  various  organs.  While  it  may  readily 
be  granted  that  the  etiological  factor  in  morbid  processes  did  not 
in  the  past  occupy  the  place  it  deserved,  it  must  be  remembered 
that  the  discoveries  recently  made  in  this  department  have  really 
been  the  means  of  elevating  etiology  into  somewhat  of  an  exact 
science,  and  in  our  enthusiasm  for  new  flelds  and  pastures  green, 
we  must  be  careful  not  to  decry  morbid  processes  in  their  anatomical 
relations.  The  idea  which  some  people  tend  to  entertain,  that 
morbid  anatomy  will  soon  be  played  out,  only  means  that  to  their 
capacity  our  knowledge  is  final,  and  that  can  hardly  be  taken  as  the 
criterion  of  omniscience.  Dr  Payne  is  not  likely  to  fall  into  this 
error — his  work  is  that  of  a  well-balanced,  clear-cut  mind  of  eminent 
ability,  embellished  with  much  experience  and  wide  acquaintance 
with  the  work  of  others.  

Studies  in  Pathological  Anatomy,  especially  in  Relation  to  Laryngeal 
Neoplasms.  Fasciculi  I.  and  II.  By  K  NoRRis  Wolfendkn, 
M.D.,  and  Sidney  Martin,  M.D.  London  :  J.  &  A.  Churchill : 
li 


In  these  fasciculi  the  authors  have  considered  in  very  full  detail 

EDINBORGH    MED.    JOURN.,    VOL.    SXXIV. — NO.   VII.  4  M 


642  STUDIES  IN   PATHOLOGICAL   ANATOMY,    P:TC.  [JAN. 

the  majority  of  tlie  benign  growths  occurring  in  the  larynx,  papil- 
loMiata,  fibromata,  myxomata,  angiomata,  lipomata,  enchoiulroinata, 
and  lymphomata.  Their  clear  and  excellent  descriptions  are 
beautifully  illustrated  by  drawings  of  microscopic  sections.  These 
are  accompanied  by  key  diagrams,  which  greatly  facilitate  their 
study.  The  book  promises  to  be  a  valuable  addition  to  our  know- 
ledge of  an  interesting,  if  rather  difficult,  corner  in  pathology. 


Elements  of  Practical  Medicine,  ^y  Alfred  H.  Carter,  M.D. 
Lond.,  Member  of  the  Royal  College  of  Physicians,  London ; 
Piiysician  to  the  Queen's  Hospital,  Birmingham.  Fifth  Edition. 
London :  H.  K.  Lewis :  1888. 

The  fact  that  this  excellent  little  introduction  to  systematic 
medicine  has  in  eight  years  reached  its  fifth  edition  says  more  in 
its  favour  than  the  most  elaborate  eulogy.  It  has  proved  of  the 
greatest  use  to  medical  students  during  these  eight  years,  and  the 
present  edition  may  as  confidently  be  recommended  in  every 
respect  as  its  predecessors. 

The  Demon  of  Dyspepsia  ;  or,  Digestion,  Perfect  and  Imperfect.  By 
Adolphus  E.  Bridger,  B.A.,  M.D.,  F.R.C.P.E.  London :  Swan, 
Sonnenschein,  Lowrey,  &  Co. :  1888. 

Among  the  many  diseases  "  flesh  is  heir  to,"  there  is  perhaps  in 
our  time  none  more  universal  than  that  which  Dr  Bridger  has 
made  a  special  object  of  study,  the  product  of  which  is  this  book. 
It  is  said  that  the  belief  in  spirits  had  its  origin  in  a  too  copious 
supper  of  roast  foe,  causing  a  nightmare,  in  which  the  troubled 
sleepers  saw  their  slaughtered  foes  menacing  them.  Since  then 
the  causes  and  symptoms  of  imperfect  digestion  have  greatly 
multiplied,  until  in  these  latter  days  the  dem  )n  dyspepsia  has 
become  a  very  Proteus,  familiar  in  one  or  more  of  his  forms  to  all 
but  the  most  exceptionally  fortunate.  Hence  the  author  thinks 
"  but  little  apology  is  needed  in  offering  this  small  work  to  the 
British  public ; "  the  reader  will  probably  conclude  that  even  were 
the  subject  of  less  general  interest,  the  author's  able  treatment  of 
it  would  remove  the  necessity  of  an  apology. 

This  book,  as  above  stated,  is  intended  for  the  British  public ; 
and  of  them,  for  the  intelligent  public,  whom  the  author  says  "  he 
should  be  paying  an  indifferent  compliment,  if,  for  the  sake  of  an 
apparent  clearness  and  simplicity,  he  were  to  omit  any  essential 
part  of  the  subject."  For  the  production  of  a  popular  work, 
perhaps  the  writer  has  gone  too  far  to  the  other  extreme,  and 
has  committed  sins  of  non-omission  which  lessen  the  popular 
character  of  the  book,  but  add  to  its  scientific  value.  The  first 
three  chapters  are  preliminary,  and  treat  of  "Man's  place  in 
Nature,"  "  Man  as  an  Individual,"  and  "  Man  as  a  Machine."    The 


1889.]  THE   DEMON   OF  DYSPEPSIA,   ETC.  6.43 

second  and  third  contain  as  much  elementary  chemistry  and 
physiology  as  will  enable  the  lay  reader  to  follow  intelligently 
the  processes  later  on  described.  The  well-known  "  steam- 
engine"  analogy  is  in  the  third  chapter  used  to  good  effect. 
Another  chapter,  supplemented  by  a  diagram  and  table,  deals 
with  the  principles  of  digestion,  and  helps  the  reader  to  under- 
stand the  digestive  process  and  the  destiny  of  the  various 
chemical  food-constituents.  When  the  author  gets  on  to  the 
main  theme  of  the  book,  he  treats  it  as  exhaustively  and  efficiently 
as  might  be  expected  from  the  painstaking  way  in  which  he  guides 
his  readers  step  by  step  in  the  early  part  of  the  book.  In  the 
sections  on  the  treatment  of  disease,  his  attention  is  to  a  large 
extent  directed  to  the  hygienic  and  dietetic  side  of  this ;  while, 
at  the  same  time,  under  the  head  of  what  he  calls  "  scientific 
treatment,"  he  gives  lists  of  prescriptions  more  likely  to  be  useful 
to  the  medical  man  than  to  the  public  at  large. 

The  author's  style  is,  as  a  rule,  clear  and  pleasant,  but  here  and 
there  throughout  the  book  there  are  involved  sentences  and  other 
evidences  of  careless  writing. 

There  are,  too,  of  necessity  points  practical  and  theoretical 
which  the  author  would  find  called  in  question  by  others  in  the 
profession,  and  on  which  the  student  might  find  it  dangerous  to 
adopt  his  views.  The  object  of  the  book,  however,  is  not  contro- 
versial, but  to  impress  upon  the  public  "  that  the  laws  of  Nature, 
as  applicable  to  the  maintenance  of  perfect  health,  are  simple  and 
intelligible,  and  that  it  is  directly  to  their  interest  to  study  these 
laws  and  to  apply  them."         

JJifendetevi  dalla  Febhre  Tifoidea.     Professore  Dott.  Carlo  Ruata, 
Prof,  di  Materia  Medica  all'  Universita  di  Perugia. 

Defend   Yourselves  from   Typhoid  Fever.     By  Dr  Carlo  Ruata, 
Professor  of  Materia  Medica,  University  of  Perugia. 

There  can  be  little  question  of  the  urgent  necessity  for  the 
solemn  warning  thus  addressed  to  the  profession  and  the  public  in 
Italy,  from  the  fact  that  every  year  from  200,000  to  300,000  indi- 
viduals are  attacked  by  this  insidious  and  persistent  malady,  and 
in  the  8257  communi  of  which  the  kingdom  is  composed  the  average 
mortality  is  27,700 ;  and,  commencing  its  ravages  from  1  year  and 
continuing  to  45  years  of  age,  the  risks  are  from  7  to  45  per  1000 
inhabitants  ;  hence  of  1000  persons  who  attain  the  age  of  45,  325 
are  seized  by  this  disease,  being  about  1  in  every  3  individuals. 
To  the  hygienist  these  statements  are  of  the  utmost  importance, 
being  intimately  connected  with  the  conditions  of  the  dwellings, 
the  soil,  and  the  water  supply,  etc. ;  and  the  prevalence  of  typhoid 
being  a  clear  indication  as  to  the  sanitary  position  of  cities  and 
districts,  and  where  it  prevails  these  are  invariably  defective. 

After  introducing  the  subject,  Professor  E-uata  proceeds  to  discuss 


644  DIFENDETEVI   DALLA   FEBBllE   TIFOIDEA,   ETC.  [jAN. 

the  specific  virus  of  typhoid.  Alluding  to  tlie  pythogenic  theories 
of  Murchison  and  Carpenter,  and  those  of  Budd  and  Coriield,  whose 
views  are  that  it  depends  on  a  specific  organic  virus  which  can  only 
originate  in  a  germ  of  identical  nature,  regarding  the  latter  as  com- 
pletely demonstrated  by  the  observations  of  Eberth  of  Zurich  in 
1880,  proving  the  causal  presence  of  a  bacillus  typhoideus  in  every 
case  of  the  malady  : — 1.  This  introduced  into  the  human  organiza- 
tion propagates  and  multiplies  itself.  2.  It  is  contained  in  the 
alvine  discharges  of  a  typhoid  patient.  3.  It  retains  its  activity 
for  an  indefinite  time  if  in  favourable  circumstances  as  regards  the 
presence  of  putrescent  animal  substance  and  humidity. 

He  proceeds  to  detail  the  particulars  of  an  outbreak  of  typhoid  in 
the  female  prison  establishment  of  Perugia  two  years  ago,  wherein 
the  facts  bore  out  these  propositions  in  a  very  striking  manner — 
showing  how  water  into  which  the  germs  have  found  access  becomes 
a  potent  agent  of  infection,  as  also  milk  in  a  minor  degree,  as  shown 
in  Dr  Wilson's  case  in  Warwickshire,  England,  and  in  the  epi- 
demic in  three  hospitals  in  Glasgow,  traced  by  Dr  Kussell  to  Kil- 
winning and  the  neighbouring  villages  of  Fergushill  and  Benslie, 

As  regards  mortality,  Italian  statistics  give  a  gloomy  picture. 
In  Larino,  prov.  Campobasso,  in  1885,  out  of  every  21  inhabitants 
1  was  stricken  mortally  by  this  fever ;  in  Schio  there  were  3-35 
deaths  per  100  inhabitants;  Pontremoli,  3-30;  San  Severo,  3-29 ; 
Beri,  3-27,  etc. ;  and  as  1  fatal  in  10  cases  seems  to  be  the  average, 
the  above,  and  numerous  other  instances  quoted,  manifest  an  amount 
of  disease  and 'danger  that  becomes  a  very  serious  national  question. 
We  see  that  no  region  in  Italy  has  any  reason  to  envy  the  others 
in  this  particular ;  what  occurs  in  the  south  is  found  in  the  central 
and  northern  provinces ;  everywhere  are  to  be  found  magistrates 
who  aspire  to  the  magisterial  power  without  having  the  conscience 
of  their  duty. 

How  are  we  to  be  freed  from  the  typlioid  fever  ?  Two  categories 
of  measures  calculated  to  attain  the  end  in  view  are  perceptible  : — 
1st,  The  measures  to  be  taken  by  the  authority,  as  representative  of 
society  ;  and  2nd,  Those  to  be  taken  by  the  individual.  How  can 
the  latter  defend  liimself  from  the  pollution  of  the  water  he  drinks, 
at  several  kilometres'  distance,  by  the  typhoid  patients'  discharges 
being  emptied  into  it  ? 

The  water  is  tiie  primary  vehicle  for  disseminating  contagion. 
Well  waters,  especially  in  cities  where,  from  a  bad  system  of 
drainage,  the  subsoil  has  become  for  centuries  infiltrated  with  ex- 
cremental  substances,  cannot  fail  to  be  pernicious,  these  being 
literally  founded  on  a  dunghill.  Some  use  torrential  water,  which 
is  as  frequently  contaminated  by  the  discharges  from  houses  or 
villages  situated  higher  up  in  tlieir  course ;  the  only  remedy  for  this 
is  the  institution  of  sanitary  ofiicers,  appointed  and  salaried  by  the 
State,  to  watch  over  the  purity  of  water-courses  supplying  cities ; 
skilled  workmen  to  attend  to  water-closets,  registered  as  in  England 


1889.]  DIFENDETEVI   DALLA   FEBBEE   TIFOIDEA,   ETC.  645 

and  America,  and  the  former  officials  empowered  to  enforce  such 
sanitary  measures  as  the  cases  require,  as  also  to  supervise  the  dis- 
tribution of  milk.  From  the  force  of  enlightened  public  opinion 
bearing  on  provincial  authorities  tlieie  is  move  to  be  hoped  for 
than  from  the  central  Government.  Unless  aided  by  Government, 
however,  the  individual  cannot  keep  himself  clear  from  this 
insidious  poison ;  but  still  he  can  often  avoid  wells  sunk  in 
impure  soils;  can  look  after  the  purification  of  cisterns,  and  see 
they  are  constructed  according  to  hygienic  rules,  and  inspected  suf- 
ficiently ;  scrutinizing  closely  the  conditions  of  latrines,  and  taking 
care  that  they  do  not  introduce  sewer  gas  poison,  are  adequately 
syphoned  and  ventilated  ;  also  the  general  dryness  and  proper 
hygienic  conditions  of  the  dwelling-house.  As  to  milk,  this  can 
always  be  rendered  innocuous  by  boiling  it  as  soon  as  received, 
after  which  it  may  be  securely  drunk. 

This  sketch  cannot  reproduce  the  lucid  elegance  of  the  style  of 
the  original.  We  have  had  previous  occasion  to  remark  on  the  high 
position  attained  by  Professor  Ruata  as  a  pharmacologist  and  thera- 
peutist at  Padova ;  his  appointment  to  the  chair  of  Materia  Medica 
at  Perugia  has  now  given  occasion  to  the  display  of  his  charac- 
teristic mental  vigour  and  acuteness,  comprehensive  learning,  and 
patriotic  devotion  to  the  best  interests  of  his  country. 


J 

Be  VEpilepsie  Jachsonnienne,  Memoire  couronnS  par  la  SociitS  de 
Medecine  et  de  CMrurgie  de  Bordeaiix.  Par  Le  Dr  E.  Rolland. 
Paris  :  Aux  Bureaux  du  Progr^s  Medical :  1888. 

To  the  medical  fraternity  in  France  this  monograph  may  be  of 
considerable  service,  in  bringing  clearly  before  them  tiie  features  of 
the  striking  malady  which  is  so  well  known  to  British  physicians 
through  the  admirable  researches  of  Hughlings-Jackson. 

The  work  is  practically  a  compilation  ;  and  the  author  has,  we 
think  wisely,  not  hesitated  to  quote  largely  from  the  works  of 
Jackson.  His  description  of  the  disease  is  little  more  than  a 
transcript  of  the  latter's  lucid  paper,  read  before  the  Medical 
Congress  in  London  in  1881. 

All  that  is  original  in  the  book  is  the  record  of  two  or  tiiree 
cases  which  have  come  under  Dr  Eolland's  immediate  notice. 

Perhaps  the  most  useful  feature  in  the  work  is  an  exceedingly 
carefully  and  laboriously  compiled  table  of  nearly  all  the  recorded 
cases  of  the  disease  in  which  post-mortem  examinations  have  been 
made,  giving  the  age  and  sex  of  the  patients,  the  parts  convulsed, 
the  parts  paralyzed,  the  chief  symptoms,  and  the  nature  and 
position  of  the  encephalic  lesion,  as  well  as  a  reference  to  the 
observer  and  place  of  publication. 

In  the  chapter  on  Diagnosis,  we  miss  any  careful  discussion  on 
the  determination  of  the  difficult  question  of  whether  the  case  is 
suitable  for  operative  treatment — a  matter  so  admirably  dealt  with 


646  DE   L'EPILEPSIE   JACKSOIsNIENNE,   etc.  [JAN. 

by  Dr  M'Ewan.  The  English  physician  will  find  nothing  new  in 
the  parts  of  the  work  devoted  to  treatment.  In  fact,  after  a  brief 
account  of  some  of  tlie  older  methods  employed,  we  find  merely  a 
translation  of  Ilorsley's  paper  read  before  the  British  Medical 
Association  two  years  ago.  It  is  curious  to  note  how  entirely  the 
author  has  ignored  all  the  recent  German  and  Russian  experi- 
mental researches  upon  the  production  and  etiology  of  convulsions. 

As  a  whole,  the  book  cannot  be  regarded  as  a  valuable  contribu- 
tion to  the  study  of  Jacksonian  epilepsy.  It  is,  in  fact,  entirely 
unworthy  of  a  student  of  the  philosophic  physician  whose  name  is 
so  closely  associated  with  the  disease.  To  demonstrate  this,  it  is 
only  necessary  to  give  the  first  of  the  author's  general  conclusions. 

*' Jacksonian  epilepsy  has  absolutely  nothing  in  common  with 
epilepsy,  except  the  name."  Every  one  who  has  devoted  any 
time  to  the  careful  study  of  convulsive  seizures  knows  perfectly  well 
that  there  is  no  hard  and  fast  line  between  Jacksonian  convulsions 
and  idiopathic  epilepsy  ;  and  that  between  seizures  associated  with 
gross  cortical  lesions  and  the  most  characteristical  idiopathic 
attacks  all  gradations  may  be  observed. 

Lectures  to  Practitioners  on  the  Diseases  of  the  Kidney  amenable  to 
Surgical  Treatment.  By  David  Newman,  M.D.,  Surgeon  to  the 
Glasgow  Western  Infirmary,  etc.  Loudon :  Longmans,  Green,  & 
Co.:  1888. 

These  lectures  were  delivered  in  1886  as  part  of  a  post-graduate 
course  given  in  Glasgow  by  Prof.  W.  T.  Gairdner,  Dr  Joseph  Coats, 
and  the  author.  They  are  very  interestingly  written,  are  illustrated 
by  numerous  cases,  and  contain  a  vast  array  of  facts  which  have 
evidently  been  collected  at  considerable  cost  of  investigation  and 
observation. 

Dr  Newman  has  made  the  kidney  his  special  study  from  the 
physiological,  the  pathological,  and  then  from  the  surgical  point  of 
view.  The  book  is  not  arranged  in  the  usual  text-book  form,  with 
divisions  into  heads  and  systematic  arrangement.  It  is  not,  there- 
fore, in  the  best  form  for  reference,  but  when  read  continuously 
gives  one  an  interest  in  the  subject,  illustrations  by  cases  or  prepara- 
tions being  brought  forward  in  support  of  every  point.  There  are 
several  valuable  tables  of  cases  operated  on,  many  of  them 
unpublished.     There  is  also  a  useful  index  at  the  end  of  the  book. 


Contributions  to  Practical  Gyncecology.  By  S.  James  Donaldson, 
M.D.,  New  York.  Read  before  the  New  York  Medico-Chirur- 
gical  Society.  New  York:  Trow's  Printing  &  Bookbinding 
Company. 

Notes  on  Diseases  of  Women.     By  James  Oliver,  M.D.  Edin.,  F.E.S. 
Edin.     London :  Hirschfield  Brothers  :  1888. 
The  above  two  works  come  fairly  under  the  category  of  essays. 


1889.]  CONTEIBUTIONS   TO   PRACTICAL   GYNECOLOGY,   ETC.  647 

Neither  of  them  professes  to  deal  with  the  whole  of  the  questions 
under  discussion,  but  in  each  case  the  author  presumes  a  full 
acquaintanceship  with  the  subject  on  the  part  of  his  readers,  and 
handles  the  matter  mainly  with  a  view  to  illustrate  and  support 
his  own  views.  Such  essays  may  or  may  not  be  of  considerable 
interest  and  value.  In  the  above  two  works  we  have  this  illus- 
trated. Dr  Donaldson's  papers  will  well  repay  perusal.  His 
criticisms  are  able  and  convincing,  and  his  reasoning  fair  and  clear. 
The  first  question  dealt  with  is  that  of  displacements ;  and  after 
showing  that  all  existing  forms  of  pessaries  are  bad,  he  describes 
and  figures  what  he  regards  as  perfect  appliances — "Dr  Donaldson's 
retroversive  and  prolapsus  pessary,"  and  "Dr  Donaldson's  adjustable 
pessary  for  the  cure  of  flexions."  Both  these  instruments  would 
seem,  from  the  description  given  of  them,  to  be  safe  and  useful. 
The  flexion  pessary  is  an  ingenious  modification  of  the  stem  and 
shelf  instruments,  the  stem  consisting  of  a  spiral  spring  surrounded 
by  soft  indiarubber  tubing,  and  the  shelf  being  a  band  of  rubber 
stretched  across  a  frame  fasliioned  somewhat  after  tlie  model  of 
the  Hodge  pessary.  The  author  states  that  it  is  easy  of  introduction, 
and  this  being  so,  we  would  say  that  the  apparatus  seems  admir- 
ably designed  to  answer  the  requirements  of  many  cases,  and  also 
seems  to  be  free  from  many  of  the  disadvantages  pertaining  to  intra- 
uterine pessaries.  The  second  part  of  the  book  is  devoted  to  dys- 
menorrhoea,  and  quite  deserves  the  title  given  to  it,  as  being  a 
thoroughly  practical  contribution  to  the  study  of  this  intricate 
subject. 

We  would  commend  the  reading  of  Dr  Donaldson's  little  volume 
to  all  interested  in  the  subject  treated  of  in  it. 


Diseases  of  Women :  A  Handbook  for  Physicians  and  Students. 
By  Dr  F.  Winckel,  Professor  of  Gynaecology  and  Director  of 
the  Eoyal  University  Clinic  for  Women  in  Munich.  Authorized 
Translation  by  J.  H.  Williamson,  M.D.,  under  the  Supervision 
of,  and  with  an  Introduction  by  Theophilus  Parvin,  M.D.,  Pro- 
fessor of  Obstetrics  and  Diseases  of  Women  and  Children  in 
Jefferson  Medical  College,  Philadelphia.  Edinburgh :  Young 
J.  Pentland :  1887. 

Wingkel's  name  and  well-known  reputation  are  a  sufficient 
guarantee  for  the  quality  of  any  work  coming  from  his  pen,  and 
English  readers  owe  a  debt  of  gratitude  to  the  translators  for  their 
labour  in  placing  the  work  within  their  reach,  and  to  the  publishers 
for  their  enterprise  and  for  the  skill  and  success  with  which  the 
numerous  original  illustrations  have  been  reproduced.  A  special 
feature  of  the  work,  to  quote  from  Dr  Parvin's  introduction,  is 
"  the  importance  given  to  pathological  anatomy,  and  thus  a  firmer 
foundation  made  for  thorough  knowledge.  Only  by  the  knowledge 
thus  acquired  can  we  learn  correctly  to  discriminate  between  dis- 


648  DISEASES   OF  WOMEN,   ETC.  [jAN. 

eases,  and  arrive  in  many  instances  at  the  appropriate  application 
of  therapeutic  agents."  The  majority  of  the  illustrations  are 
representations  of  pathological  specimens,  and  we  entirely  miss, 
without  much  regret,  the  plates  of  instruments,  pessaries,  etc.,  etc., 
which  are  so  freely  introduced  in  the  various  text-books  of  gynae- 
cology. 

As  a  work  of  reference  on  the  anomalies  and  diseased  conditions 
of  the  sexual  organs,  the  book  before  us  will  form  a  valuable 
addition  to  the  library  of  the  specialist.  As  regards  treatment 
the  author,  while  not  neglecting  the  most  recent  advances  in 
gynaecological  surgery,  is  eminently  conservative  in  much  of  his 
teaching,  and  gives  great  importance  to  gynaecological  medicine. 
To  quote  again  from  Dr  Parvin's  introduction — "  No  one  can  read 
and  thoroughly  study  this  volume  without  deriving  not  only  much 
important  practical  information,  but  also  finding  his  views  of 
gynaecology  growing  larger,  and  the  superstructure  resting  upon 
a  broader  and  firmer  foundation." 


La  Goutte  sa  Nature  et  son  Traitement.  Par  Dr  W.  Ebstein, 
Professeur  de  M^decine  a  I'Universite  de  Goettingue.  Traduc- 
tion du  Dr  E.  Chambard.  Introduction  du  Professeur  Charcot. 
Paris :  J.  Eothschild :  1887. 

This  important  and  valuable  monograph  on  Gout  by  Professor 
Ebstein  has  been  translated  into  French,  and  the  value  of  the 
work  it  presents  is  guaranteed  by  an  introduction  by  Professor 
Charcot. 

After  a  short  resume  of  the  historical  relations  of  the  subject, 
the  second  chapter  takes  up  its  pathological  anatomy,  and  here  we 
shall  only  indicate  the  author's  contentions  on  tliis  point.  He 
maintains  that  in  the  histological  alterations  which  are  character- 
istic and  typical  of  gout  there  is,  beyond  the  deposit  of  crystalline 
urates,  an  alteration  which  is  common  to  them,  and  that  is  the 
necrosis  of  the  tissues  and  the  organs  at  the  seat  of  these  deposits. 
This  necrosis  he  regards  as,  in  a  way,  specific,  because  he  has 
never  found  it  absent.  In  fact,  he  regards  the  combination  as 
characteristic  of  the  gouty  process.  The  area  of  tissue  necrosis 
extends  somewhat  beyond  the  area  containing  the  deposit.  The 
development  of  these  necrotic  areas  is  preceded  by  a  stage 
which  he  calls  the  necrosing  stage,  in  which  the  death  of  the 
tissue  is  not  complete,  and  in  this  stage  there  is  no  deposit  of 
crystalline  urates.  The  first  change,  he  insists,  is  a  nutritive 
change  in  the  tissues  which  goes  on  to  necrosis,  and  that,  follow- 
ing upon  that,  there  is  the  deposit  of  crystalline  urates.  The 
conditions  which  lead  to  the  death  of  the  tissues  is  the  gouty 
material  which  accumulates  at  the  part  in  a  liquid  form.  The 
process  of  crystallization  in  a  necrosed  area  has  its  analogue  in 


1889.]         LA.   GOUTTE   SA   NATUEE   ET   SON   TRAITEMENT,   ETC.  649 

the  deposit  of  calcareous  salts  in  tissues,  the  nutrition  of  which 
has  been  impaired. 

The  author's  contentions  are  supported  by  an  experimental 
inquiry  of  considerable  value,  the  details  of  which  we  cannot 
attempt  to  give  here. 

The  volume  ends  with  a  clinical  study  of  gout :  first,  as  primarily 
attacking  the  joints ;  second,  as  primarily  attacking  the  kidney. 

The  coloured  illustrations  are  of  great  beauty,  and  the  work  is 
well  worthy  of  perusal  by  those  who  have  not  already  seen  it  in 
the  original.  

Em'pycBma :  a  MetJwd  of  Subcutaneous  Drainage.  By  G.  J. 
KoBERTSON,  M.B.,  CM.,  Surgeon  to  the  Oldham  Infirmary. 
Reprinted  from  the  Med.  Chronicle. 

Mr  Robertson  suggests  a  method  of  draining  an  empyaema 
that  seems  to  recommend  itself.  The  idea  is  to  get  out  the  pus 
in  such  a  way  that  air  shall  not  enter.  Expansion  of  the  lung, 
the  most  important  agent  in  effecting  a  cure,  is  thus  encouraged. 

Mr  Robertson  publishes  thirteen  cases,  of  which  ten  ended 
satisfactorily,  there  being  three  deaths.  The  average  age  of  the 
successful  cases  was  a  little  over  four  years.  We  know  that  in 
children  recovery  from  empysema  is  common,  whatever  method  of 
treatment  is  adopted.  Mr  Robertson's  results,  therefore,  are  not 
unusual  except  in  regard  to  time,  cure  being  effected  in  a  few 
weeks — in  one  case  in  ten  days.  The  apparatus  employed  by  Mr 
Robertson  is  complicated.  It  is  to  be  hoped  that  some  simpler 
adaptation  of  the  valvular  principle  in  drainage  may  be  suggested. 


Le  Crachat  dans  ses  Rapports  avec  le  Diagnostic,  le  Pronostic,  et  le 
Traitement  des  Maladies  de  la  Gorge  et  des  Poumons.  Par  le  Dr 
Hunter  Mackenzie,  d'Edimbourg.  Traduit  et  Annote  par  le 
Dr  Leon-Petit.  Pr^c^de  d'une  Preface,  par  le  Professeur 
Gkancheur.     Paris :  Octave  Doin :  1888. 

Dr  Hunter  Mackenzie's  work  on  The  Sputum  is  well  known 
to  the  majority  of  our  readers.  It  was  reviewed  in  these  columns 
about  two  years  ago.  It  was  well  received  by  the  profession  in 
this  country,  and  now  a  French  translation  has  appeared.  This 
translation  has  been  made  by  Dr  Ldon-Petit,  who  has  also  enriched 
the  book  by  some  very  valuable  notes.  Prof.  Grancheur  has  written 
a  commendatory  preface,  in  which  he  speaks  highly  of  Dr  Mac- 
kenzie's observations  from  the  clinical  side.  It  is  quite  a  charming 
volume  in  its  French  dress,  and  compares  very  favourably  with  the 
English  edition.  We  have  no  doubt,  after  reading  Prof.  Grancheur's 
preface,  that  it  will  be  popular  among  our  French  brethren. 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.   VII.  4  N 


650   QUAND  ET  COMMKNT  DOIT-ON  PRESCRIBE  LA  DIGITALE,  ETC,   [jAN. 


Quand  et  Comment  Doit-on  Prescrire  la  Digitale.  Par  Henri 
HuCHARD,  M^decin  de  I'Hopital  Bichat.  Paris :  Librairie 
Medicale  Leclerc :  1888. 

This  little  work  contains  much  that  is  of  the  greatest  use  to  the 
medical  practitioner,  conveyed  in  terms  at  once  terse  and  clear,  some 
ot"  the  statements  being  almost  worthy  of  being  termed  epigram- 
matic. It  contains  a  critical  survey  of  the  action  of  the  drug, 
followed  by  a  careful  analysis  of  the  indications  for  its  employment, 
and  the  symptoms  which  render  its  use  unadvisable.  It  is  impos- 
sible to  agree  with  all  the  conclusions  which  are  reached  by  the 
author,  but  it  is,  at  the  same  time,  equally  impossible  not  to 
recognise  the  clinical  acumen  and  therapeutic  resource  of  the 
author.     The  work  is  eminently  worthy  of  careful  perusal. 


La  Fihvre  typhoide  trait^e  par  les  hains  froids.  Par  E.  Tkipier, 
Professeur  h,  la  Faculty  de  M^decine,  Medecin  des  Hopitaux  de 
Lyon;  et  L.  Bouvkket,  Agrdg^  '^  la  Faculte  de  Medecine, 
Medecin  des  H6pitaux  de  Lyon.  Paris:  Librairie  J.  B.  Baillifere 
et  Fils.     Lyon  :  Henri  Georg  et  J.  P.  Megret:  1886. 

Although  published  two  years  ago,  this  work  has  only  now 
reached  us,  and  we  hasten  to  make  a  {%vf  remarks  upon  it.  It 
begins  with  an  excellent  historical  review  of  the  use  of  cold  water 
in  disease  from  the  days  of  Hippocrates  down  to  the  present  time, 
forming  one  of  the  best  written  descriptions  of  the  gradual  develop- 
ment of  opinion  in  regard  to  the  medical  uses  of  cold  water  with 
which  we  are  acquainted.  Personal  observations  follow,  embody- 
ing statistical  results,  and  the  authors  afterwards  pass  on  to  the 
consideration  of  indications,  and  contra-indications,  complications, 
effects  of  cold  baths,  progress  and  duration,  prognosis  and  mortality, 
which  lead  up  to  a  careful  description  of  the  methods  to  be 
employed  in  the  use  of  cold  batiis  in  this  condition.  The  work 
is  characterized  by  extreme  care  throughout,  and  may  be  regarded 
as  one  of  the  most  important  contributions  to  this  subject  within 
recent  times. 

Hydrophobia :  A  Revieio  of  Pasteur's  I'reatment.  By  W.  Collier, 
M.A.,  M.D.  Cantab,  M.KC.P.,  Physician  to  the  Eadciiffe  Infir- 
mary, Oxford.     London  :  H.  K.  Lewis :  1888. 

This  pamphlet  of  30  small  pages  "has  been  written  with  the 
hope  of  making  Pasteur's  many  valuable  discoveries,  and  the  experi- 
mental evidence  and  other  facts  on  which  his  treatment  of 
hydrophobia  is  based,  more  widely  known  to  the  general  public." 

The  author  seems  to  think  that  because  Pasteur  proved  that 
fermentation  was  due  to  the  action  of  minute  organisms,  that  the 


1889.]  HYDKOPUOBIA,   ETC.  661 

p^brine  of  silkworms  was  also  bacterial ;  that  splenic  fever  was 
caused  by  bacilli  and  chicken  cholera  by  another  organism,  and 
that  in  both  cases  an  attenuation  of  the  virus  could  be  brought 
about  by  certain  treatment ;  and  that  inoculation  with  this  mitigated 
virus  made  the  respective  animals  experimented  on  refractory  to  the 
strongest  similar  virus ;  it  is  quite  a  likely  supposition  that  he  is 
also  right  with  regard  to  hydrophobia.  He  details,  in  popular  form, 
how  Pasteur  gradually  arrived  at  his  conclusions,  and  ventured  at 
length  to  try  his  methods  of  inoculation,  unfailing  in  dogs,  on  man. 
How  far  Pasteur  has  been  successful,  and  how  much  he  has  failed, 
are  still  questions  siih  judice  •  and  Dr  Collier  does  nothing,  nor 
does  he  pretend  in  his  hrochure  to  help  to  settle  the  question  by 
argument  or  experiment.  The  reviewer  agrees  with  Dr  Gordon  in 
thinking  that  the  policeman  and  the  muzzle  would  stamp  out  rabies 
more  efficiently  than  the  scientist. 


Therapeutics :  its  Principles  and  Practice.  By  H.  C.  Wood,  M.D., 
LL.D.,  Professor  of  Materia  Medica  and  Therapeutics,  and  Clinical 
Professor  of  Diseases  of  the  Nervous  System,  in  the  University 
of  Pennsylvania.  Seventh  Edition,  rewritten  and  enlarged. 
London  :  Smith,  Elder,  &  Co. :  1888. 

The  fact  that  the  seventh  edition  of  Wood's  Therapeutics  has 
appeared  within  three  years  of  the  publication  of  the  sixth  edition, 
shows  the  great  popularity  of  this  work.  The  work  is  well  known 
as  a  standard  treatise  on  therapeutics,  not  only  in  America,  but  also 
in  this  country. 

This  edition  differs  from  previous  ones  in  some  particulars, 
but  only  to  increase  the  value  of  the  book.  The  present  edition 
has  interesting  chapters  on  Massage,  Feeding  of  the  Sick,  Dietetics, 
etc. 

The  author  has  brought  his  work  well  up  to  date  by  introducing 
articles  on  such  new  drugs  as  hydrastin,  strophanthus,  iodol, 
urethan,  papain,  etc. 

The  work  is  too  large  (908  pages)  for  a  students'  text-book,  but 
is  one  which  students  would  do  well  to  possess,  and  as  a  work  of 
reference  will  form  a  most  valuable  addition  to  the  library  of  every 
member  of  the  medical  profession. 


Mind  and  Matter :  A  Sermon  preached  before  the  British  Medical 
Association  on  Tuesday,  7th  August  1888.  By  John  Caird, 
D.D.,  LL.D.,  Principal  of  the  University  of  Glasgow.  Published 
by  request  of  the  Association.  Glasgow :  James  Maclehose  & 
Sons:  1888. 

This  magnificent  contribution  to  Theism  from  one  of  the  master 
thinkers  of  the  age  well  deserves  a  permanent  place  in  type.  It 
will  repay,  as  it  needs,  deep  study.     It  meets  the  materialist  on  his 


652  MIND   AND   MATTER,   ETC.  [jAN. 

own  ground,  and  foils  his  attack  with  his  own  weapons.  The 
argument  for  a  God  and  for  a  religion  is  taken  in  this  duel  not  from 
Kevelation,  but  from  science.  The  simple  Christian  man  who 
accepts  his  Bible  will  neither  need  nor  greatly  value  the  powerful 
reasoning,  but  to  use  Principal  Caird's  own  words  in  his  noble 
peroration — "  It  is  some  reward  of  a  truer  speculation  if  it  enables 
us  to  put  away  this  phantom  of  nescience,  and  to  think  of  God  as 
the  God  of  truth,  of  science,  the  Being  whose  dwelling-place  is 
not  thick  darkness,  but  wherever  knowledge  sheds  its  kindly  light 
over  the  paths  of  men,  whom  every  true  thought,  every  fresh 
discovery,  every  idea  of  the  wise,  and  every  intuition  of  the  good 
are  helping  us  to  know  more  fully — the  Being,  in  one  word,  who  is 
Himself  the  Truth  absolute  and  inexhaustible,  after  which  the 
greatest  of  the  sons  of  men  have  sought  with  a  thirst  which  is 
unquenchable,  and  which,  when  they  have  in  any  measure  grasped 
it,  is  the  inestimable  reward  of  all  their  endeavours." 


The  Son  of  a  Star :  a  Romance  of  the  Second  Century.  By  Ben- 
jamin Ward  Richardson.  In  3  volumes.  "Ficta  voluptatis 
causa,  sit  proxima  veris," — Hor.  London  :  Longmans,  Green,  & 
Co.:   1888. 

Novel  reading  may  be  allowed  to  the  wearied  medical  man  in 
his  arm-chair  as  a  diversion  to  his  mind  from  more  serious  subjects, 
though,  alas !  too  frequently  the  sorrows  we  see  in  real  life,  and  the 
hidden  skeletons  in  many  an  unexpected  closet,  call  so  much  on 
the  sympathies  of  the  doctor  that  he  can  hardly  be  troubled  with 
unreal  anxieties  and  imaginary  catastrophes.  Novel  reviewing  is 
not  much  in  the  line  of  a  serious  medical  monthly,  in  which  the 
scientific  use  of  the  imagination  confines  itself  to  the  loves  of  the 
plants  or  the  hates  of  the  micrococci. 

But  when  a  man  in  the  first  rank  of  the  profession,  an  original 
thinker  in  many  branches  of  science,  a  veteran  physiologist,  and  a 
most  suggestive  and  learned  physician,  spends  his  leisure  time  in 
the  writing  of  a  novel,  it  deserves  our  fullest  attention. 

How  Dr  Benjamin  Ward  Richardson  obtained  the  leisure  is  a 
marvel.  The  work  he  gives  to  the  profession  every  quarter  in  his 
Asclepiad  would  be  too  much  for  any  ordinary  glutton  for  work. 
But  here  it  is  in  three  handsome  volumes,  fit  for  any  circulating 
library.  A  very  remarkable  novel  it  is,  full  of  incident,  of  battle, 
murder,  sudden  death,  love-making,  politics,  history,  geography, 
science,  and  humour. 

We  will  not  forestall  the  reader's  pleasure  by  telling  even  the 
outline  of  the  story.  It  is  a  tale  of  the  second  century,  with  a  hero 
and  two  heroines,  plenty  of  noble  Romans,  crafty  Jews,  and  even  a 
comic  subordinate  hero  and  heroine.  There  are  admirable  descrip- 
tions of  Roman  camps  and  scenery  both  in  Britain  and  Palestine, 
a  most  touching   deathbed  of  a  fine    old    centurion,  glimpses  of 


1889.]  THE   SON   OF   A   STAR,   ETC.  653 

emperors  and  procurators,  priests  and  pagans.  There  is  one  very 
curious  underlying  characteristic,  that  while  the  writer's  sympathies 
seem  to  be  with  that  marvellous  race  which  hastes  not,  neither 
rests,  which  is  stubborn,  crafty,  and  rebellious,  the  reader's  sympathy 
will  almost  certainly  follow  the  Roman  leaders  and  centurions,  who 
by  simple  discipline  seem  unexpectedly  to  win  in  the  end.  It  is 
also  curious  to  mark  the  strange  youthfulness  and  overflowing 
vitality  of  the  whole  story.  It  is  full  of  promise  for  the  future  if 
the  author  will  write  more  novels;  for  what  faults  tiie  book  has 
are  those  that  pruning  will  cure.  What  we  like  least  is  the 
comedy,  possibly  because  we  don't  quite  see  the  joke.  There  is  a 
chapter  on  Novimagians,  who  live  about  seven  miles  from  London, 
who  amuse  the  Emperor  Hadrian  more  tlian  they  do  us,  and  the 
whole  Irish  question  as  dimly  shadowed  to  our  possibly  too  old 
and  dim  eyes  seems  unnecessarily  Utopian.  The  virtues  of  fresh 
air,  temperance,  and  fair  water  are  lauded  most  wisely.  Dr 
Richardson  has  really  made  a  great  hit  in  a  new  line  of  work,  and 
given  novel  readers  a  book  wise  and  witty,  powerful  and  yet  abso- 
lutely pure  and  healthy. 

Witli  a  weaker  man  the  fighting  would  have  become  massacre  ; 
with  a  less  wise  one,  the  simplicity  of  the  age  might  have  been 
coarseness.  

The  A.  B.  G.  Medical  Diary  and  Visiting  List ;  vHth  which  is  com- 
bined the  A.  B.  C.  Materia  Medica  and  Numerous  Tables  prepared 
especially  for  ready  reference  by  Medical  Men.  Price  2s.  each. 
Burroughs,  Wellcome,  &  Co.,  London,  1889. 

This  is  a  wonderfully  cheap  compendium  of  information  as  to 
drugs,  new  and  old,  irritant  poisons, and  the  like,  bound  up  in  compact 
form  into  a  pocket  diary,  which  includes  visiting  list,  cash  accounts, 
memoranda.  No  medical  man  need  miss  an  opportunity  from  for- 
getfulness  or  be  at  a  loss  at  the  prescribing  of  new  drugs  if  he  carries 
this  little  book  in  his  pocket. 


MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY    OF  EDINBURGH. 

session    LXVIII. — MEETING    II. 
Wednesday,  5th  December  1888. — Dr  John  Smith,  President,  in  the  Chair. 

I.  Election  of  New  Members. 

The  following  gentlemen  were  elected  ordinary  members  of  the 
Society  : — George  P.  Boddie,  M.B. ;  Kenneth  Mackinnon  Douglas, 


654  MEETINGS   OF   SOCIETIES.  [jAN; 

M.B.,  CM. ;  G.  Lovell  Gulland,  M.B.,  M.A.,  B.Sc,  M.RC.P.  Ed. ; 
W.  Bum  Macdonald,  M.A.,  M.B. ;  James  W.  Martin,  M.D. 

II.  Exhibition  of  Patient. 

Professor  Grainger  Stewart  showed  a  case  of  gout  with  numerous 
tophaceous  deposits  in  the  skin.  The  patient  was  a  man,  aged  58, 
who  had  suffered  from  gout  for  twenty-three  years,  the  hands 
having  gradually  become  so  deformed  as  to  make  work  impossible 
for  a  long  time  past.  Till  lately  there  was  no  manifestation  except 
in  the  joints  and  skin,  but  albuminuria  had  now  appeared,  and 
hyaline  casts  were  sometimes  seen.  Probably  there  was  no  case 
on  record  with  so  many  deposits  in  the  skin.  The  case  was  well 
known  in  the  London  hospitals,  and  has  been  referred  to  by  Dr 
Pye  Smith  in  the  last  edition  of  Hilton  Fagge's  book.  The  family 
history  could  be  traced  back  at  least  a  hundred  years  on  both 
father  and  mother's  side,  and  there  was  absolutely  no  case  of  gout 
on  either.  Though  he  was  not  an  abstainer  he  was  not  a  self- 
indulgent  man,  and  his  personal  habits  did  not  give  them  any  clue 
to  the  cause  of  the  early  and  severe  development  of  the  disease. 

III.  Exhibition  of  Instkument. 
Dr  James  Foulis  showed  a  new  form  of  aspirator  syringe. 

IV.  Exhibition  of  Pathological  Specimens. 

1.  Mr  Scott  Lang  showed  for  Mr  Joseph  Bell  a  carcinoma  of 
the  mamma  associated  with  Paget's  disease  of  the  nipple,  and  a 
cast  by  Mr  Cathcart  showing  the  external  appearance  of  the  breast 
immediately  after  removal  and  before  a  section  was  made.  A 
microscopical  specimen  was  also  shown.  Under  the  microscope 
the  condition  of  the  breast  was  seen  to  be  very  similar  to  that 
recently  described  by  Sir  Spencer  Wells  as  alveolar  cancer,  or 
otherwise  as  duct-cancer.  There  was  a  history  of  heredity  in  the 
case,  Mr  Bell  having  seen  in  consultation  the  lady's  aunt  for  a 
precisely  similar  condition,  which  had  come  on  late  in  life  and 
lasted  for  many  years.  No  operation  was  possible  in  her  case,  on 
account  of  advanced  age  and  frequent  attacks  of  hemiplegia  with 
aphasia.  The  eczema  appeared  to  have  begun  in  the  areola  around 
the  nipple,  and,  according  to  Sir  Spencer  Wells,  was  connected  with 
the  orifices  of  the  sweat  glands  in  the  areola.  In  this  case  the  patient 
made  a  rapid  recovery,  and  the  prognosis  in  such  cases  was  favour- 
able, according  to  Sir  Spencer  Wells  in  his  recent  lectures  on 
cancer  and  cancerous  diseases. 

2.  Prof.  Chiene  showed  specimens  recently  added  to  his  class 
museum,  (a.)  The  first  of  these  consisted  of  a  series  of  urinary 
calculi  from  four  patients — three  male  and  one  female.  One  of 
the  male  patients  was  a  boy  aged  4^  years,  the  point  of  interest 
in  his  case  being  an  illustration  of  the  risk  during  operation  of 


1889,]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  655 

tearing  the  membranous  urethra  and  pushing  the  bladder  up 
into  the  abdomen.  As  Mr  Chiene  introduced  his  finger,  he  felt 
the  urethra  beginning  to  give.  He  therefore  desisted,  and  incised 
the  neck  of  the  bladder  more  freely.  The  other  two  were  adults, 
aged  52  and  60  respectively.  In  the  former,  there  was  rigidity 
of  the  prostate  requiring  free  division,  which  resulted  in  con- 
siderable delay  in  the  healing  of  the  sinus.  In  the  latter,  the 
prostate  was  so  much  enlarged  that  the  finger  could  not  reach 
the  bladder.  In  the  female,  aged  20,  the  trouble  was  due  to  the 
introduction  of  a  foreign  body.  Dilatation  of  the  urethra  was 
found  insufficient,  and  an  incision  had  to  be  made  into  the  floor 
of  the  urethra  before  the  stone  could  be  removed.  Neither  incon- 
tinence nor  retention  followed  the  operation.  (&.)  Tumours.  Of 
these,  three  were  exostoses — one  of  the  lower  end  of  the  fibula  in 
a  patient  aged  30,  and  ascribed  to  a  strain  twelve  years  before, 
another  of  the  femur  in  a  patient  aged  18,  and  the  third  from  the 
posterior  border  of  the  scapula  of  a  patient  aged  15.  The  fourth 
was  a  cartilaginous  tumour,  growing  from  the  perichondrium  of 
the  fourth  left  rib  at  the  junction  of  the  cartilage  with  the  bone. 
It  was  removed  by  crescentic  incision  at  the  lowest  part  of  the 
tumour,  by  which  the  skin  and  pectoral  muscle  could  be  easily 
raised  from  the  surface  of  the  growth.  As  the  attachments  could 
not  be  made  out  easily,  the  tumour  was  removed  in  slices.  A  cast 
showed  the  appearances  before  removal.  Fifth,  two  bursal  tumours, 
one  from  the  right,  the  other  from  the  left  patella  of  the  same 
patient.  The  right  had  existed  for  thirteen  years,  the  left  for  six. 
Sixth,  a  myeloid  sarcoma  of  the  lower  jaw  of  a  man  aged  59.  It  had 
existed  for  nine  months.  Half  of  the  jaw  was  removed  immediately 
after  a  preliminary  tracheotomy.  Four  days  after,  symptoms  of 
pneumonia  appeared;  eleven  days  after  the  occurrence  of  the  pneu- 
monia, there  was  evidence  of  gangrene  of  the  lung,  and  death  took 
place  in  forty-eight  hours.  Prof.  Chiene  was  inclined  to  think  that 
there  must  have  been  some  regurgitation  of  food  from  the  stomach 
into  the  trachea  which  would  account  for  the  result.  Seventh,  a 
fibro-cellular  tumour  from  a  patient  aged  25.  It  was  situated 
below  the  auricle,  and  had  first  been  observed  ten  or  twelve 
years  before,  (c.)  Tubercular  testes,  removed  on  separate 
occasions  from  the  same  patient  (aged  30).  The  left  was  first 
affected  after  a  blow.  Five  months  after  its  removal  he  returned 
with  the  epididymis  of  the  right  enlarged  and  diseased,  (d.)  A 
BRAIN  with  an  abscess  in  the  frontal  lobe.  The  patient  was  a  boy 
aged  13.  Four  months  before  admission  he  was  hit  on  the  fore- 
head by  a  snowball.  An  abscess  formed,  which  was  lanced  and 
healed  up.  Three  months  later,  after  a  cold,  the  swelling  returned, 
and  was  opened  the  day  before  admission  into  the  Hospital.  The 
sinus  was  explored,  and  an  exfoliation  removed  from  the  external 
angular  process  of  the  frontal  bone.  The  pulse  was  rather  slow, 
but,  beyond  complaining  of  headache  on  the  tenth  and  eleventh  days 


656  MEETINGS   OF   SOCIETIES.  [jAN. 

after  admission,  he  showed  no  symptoms  of  brain  mischief.  On  the 
21st  day  he  ate  a  quantity  of  cheese  brought  in  by  a  relative.  This 
was  followed  by  vomiting  and  pain  in  the  stomach.  The  follow- 
ing day  he  complained  of  pain  under  the  chin;  in  the  afternoon 
he  was  screaming  loudly  and  complaining  of  pain  in  the  neck  and 
frontal  region.  Meningitis  was  then  diagnosed.  He  died  the 
same  night,  and  at  the  post-mortem  examination  a  subdural  abscess, 
about  the  size  of  a  walnut,  was  found  in  the  frontal  lobe,  (e.) 
Astragalus  and  foot  showing  the  perforating  ulcer  of  locomotor 
ataxy.  The  astragalus  was  lying  bare,  and  was  lifted  out  when 
the  patient  was  admitted.  (/.)  A  specimen  showing  the  effect  of 
operation  for  kadical  cuke  of  inguinal  hernia.  The  hernia  had 
been  reduced  four  days  before  admission  into  hospital ;  the  symp- 
toms of  strangulation,  however,  continued,  and  the  hernia  was 
therefore  cut  down  upon.  It  was  then  found  that  reduction  en  bloc 
had  occurred,  the  constriction  was  divided,  and  the  radical  opera- 
tion performed.  The  patient  was  doing  well  till,  on  the  twenty- 
third  day  after  operation,  he  was  seized  with  angina  pectoris,  and 
died  suddenly.  The  specimen,  obtained  post-mortem,  showed 
closure  and  dimpling  opposite  the  internal  abdominal  opening. 
(g.)  Hammer-toe,  showing  contraction  of  the  fibrous  structures, 
as  well  as  of  the  flexor  tendons,  (h.)  A  couple  of  peas.  A 
stout  middle-aged  woman  put  these  in  her  mouth  when  feeding 
pigeons.  One  of  them  passed  down  "  the  wrong  way."  She 
brought  the  other  with  her  to  hospital  to  show  it.  There  was 
some  difficulty  of  breathing  for  twenty-four  hours  after  the 
accident.  She  was  kept  in  bed,  and  a  pneumonic-like  sputum 
appeared,  but  no  physical  signs.  This,  as  well  as  the  cough, 
passed  off,  and  on  the  twelfth  day  she  was  allowed  to  go  home. 
On  going  upstairs  she  coughed  out  the  pea  which  had  lain  in  her 
bronchus  for  twelve  days.  (/)  A  discoidal-shaped  whistle,  larger 
than  a  halfpenny,  which  had  lain  in  a  child's  intestinal  canal  for 
twelve  days  and  then  passed  per  anum.  (^^)  Fragments  of  bone 
removed  from  the  lower  jaw  by  trephining.  The  operation  was 
performed  for  resection  of  portions  of  the  lingual  and  inferior 
dental  nerves  to  relieve  the  pain  of  an  epitheliomatous  ulcer  of 
the  tongue.  Forty-eight  hours  after  the  operation  there  was  con- 
siderable salivation  and  bleeding  from  the  ulcer,  due  apparently 
to  irritation  at  the  peripheral  end  of  the  divided  chorda  tympani 
inhibitory  and  secretory  fibres  of  the  lingual  nerve.  So  far  as  the 
relief  of  pain  went,  it  had  been  a  success,  (l.)  Microscopic  sections 
of  the  fibro-cellular  tumour,  a  healing  ulcer,  and  a  hard  chancre 
were  also  shown. 

3.  Mr  J.  M.  Gotterill  showed  a  perforated  vermiform  appendix. 

V.  Original  Communication. 
Mr  J.  M.  Cotterill  read  his  paper  on  a  case  of  gangrene  of 


* 


1S89.]  MEDICO-CHIRUIIGICAL   SOCIETV    OF   EDINBURGH.  657 

THE  TRANSVERSE  COLON  IN  AN  UMBILICAL  HERNIA,  which  appears  Oil 

page  602  of  this  Journal. 

The  President  said  he  believed  he  was  only  expressing  the 
feeling  of  every  member  present  in  saying  how  much  the  Society 
was  indebted  to  Mr  Cotterill  for  the  communication  just  read.  The 
case  had  been  a  very  remarkable  one;  many  great  and  remarkable 
operations  had,  since  the  founding  of  the  Royal  Infirmary,  now 
more  than  100  years  ago,  been  performed  within  its  walls ;  some 
of  them,  in  one  way  or  other,  not  having  obtained  sufficient  credit 
throughout  the  world  as  having  originated  or  been  brought  to  per- 
fection in  Edinburgh.  Not  a  few  of  these  remarkable  operations 
had  been  recorded  in  the  minutes  of  the  Medico-Chirurgical 
Society,  and  the  operation  just  detailed  was  one  most  certainly 
deserving  a  distinguished  place  among  them.  Laparotomy,  in  the 
most  extended  signification  of  the  term,  had  of  late  years  claimed 
for  itself  a  new  position  in  operative  procedure,  not  only  in  ob- 
stetric practice,  but  in  the  treatment  of  various  diseases  of  the 
stomach,  liver,  gall-bladder,  kidneys,  intestines,  and  in  those  com- 
plications sometimes  involved  in  the  different  forms  of  hernia.  He 
should  wish  to  hear  the  remarks  of  some  of  the  surgeons  present 
on  such  a  subject,  and  trusted  it  would  meet  with  a  full  discussion 
towards  its  further  elucidation. 

Professor  Chienc  considered  Makins'  instrument  an  improve- 
ment on  the  other  clamps  which  were  shown.  He  was  favourably 
impressed  by  the  fineness  of  the  needles  used,  and  though  he  could 
not  speak  from  practical  experience,  Czerny's  suture  appeared, 
from  what  Mr  Cotterill  had  said,  an  improvement  on  Lembert's. 

Mr  F.  M.  Caird  hailed  Mr  Cotte rill's  paper  as  an  interesting 
addition  to  what  had  been  done  in  intestinal  surgery.  It  was  a 
curious  fact  that  in  this  School  the  celebrated  Benjamin  Bell  was 
one  of  the  first  to  advocate  this  operation,  ami  was  opposed  by  the 
no  less  celebrated  John  Bell.  One  of  the  first  difficulties  in  operat- 
ing on  the  intestinal  canal  lay  in  the  prevention  of  an  escape  of 
faical  matter.  This  difficulty  was  so  great  that,  in  the  event  of 
being  called  on  in  private  practice  to  treat  such  a  case  with 
limited  assistance,  it  was  a  matter  of  great  doubt  how  to  proceed. 
Some  time  since  he  was  called  in  the  middle  of  the  night  to  a 
lady  w^ell  up  in  years  who  suffered  from  acute  intestinal  obstruc- 
tion with  fffical  vomiting  of  some  days'  duration.  She  had  fatty 
heart,  and  had  recovered  from  a  hemiplegic  attack.  Abdominal 
section  was  performed,  and  a  gall-stone  found  impacted  in  the 
lower  intestine.  It  could  not  be  driven  down,  and  when  puslied 
up  was  sent  back  again  by  the  fsecal  movement.  It  was  so  hard 
that  it  could  not  be  broken  up.  To  cut  into  the  gut  without 
assistance  in  view  of  f;ecal  extravasation  was  not  lightly  to  be 
thought  of  Mr  Cotterill's  plan  of  a  rubber  clamp  passed  through 
a  hole  in  the  mesentery  could  hardly  be  used  in  such  a  case,  as 
its  tendency  would  be  to  make  folds  in  the  bowel,  whereas  they 

EDINBURGH   MED.    JOURN..    VOL.    XXXIV.— NO.    VII.  4  O 


658  MKETINGS    OF   SOCIETIES.  [jAN. 

desired  to  have  it  flattened  out  for  convenieirce  in  suturing. 
Under  tliese  circumstances  the  intestine  was  stitched  to  the 
abdominal  wall,  and  after  the  elapse  of  some  hours  the  stone  was 
cut  out.  This  was  done  successfully ;  no  fecal  escape  occurred. 
On  the  fiftii  day,  however,  the  patient  died  of  cardiac  syncope, 
without  a  trace  of  peritonitis.  In  other  instances  they  had  to 
deal  with  a  gut  already  ruptured.  In  the  case  of  an  old  woman, 
practically  at  death's  door  from  strangulated  hernia  of  more  than 
a  week's  duration,  it  was  thought  right  to  relieve  the  constriction. 
As  this  was  divided  the  gut  accidentally  slipped  back  into  the 
pelvic  cavity.  The  patient  couglied,  and  a  gush  of  feecal  matter 
poured  out.  There  was  nothing  for  it  but  to  extend  the  incision, 
find  the  gut,  and  stitch  it  to  the  wound,  so  as  to  make  a  fsecal 
fistula.  Warm  boric  lotion  was  meanwhile  being  pumped  into  the 
peritoneal  cavity,  and  the  faecal  extravasation  washed  out.  The 
patient  rallied  but  slightly,  and  at  the  post-mortem  the  peritoneal 
cavity  was  found  perfectly  clean.  Again,  some  years  ago,  he  had 
to  deal  with  a  gut  which  was  gangrenous.  There  was  no  faecal 
extravasation.  The  ruptured  part  was  closed  with  Lembert's 
suture,  and  the  patient  did  well.  When  a  faecal  fistula  was  estab- 
lished, unless  the  patient  was  obviously  losing  ground,  he  would 
not  recommend  such  extensive  operations,  which  involved  opening 
the  peritoneal  cavity  ;  besides,  faecal  fistulae  had  a  natural  tendency 
to  close.  He  considered  that,  generally,  it  was  better  to  adopt 
some  milder  measure  which  was  not  attended  with  risk,  such  as 
the  plan  used  by  Banks,  where  a  moored  rubber  drainage-tube  is 
inserted.  In  a  case  of  faecal  fistula  which  had  ensued  from  an 
abscess  forming  after  an  exploratory  laparotomy,  he  had  himself 
employed  with  considerable  success  the  method  so  well  known  in 
Edinburgh  of  splitting  the  fistulous  area  into  its  original  visceral 
and  cutaneous  portions,  and  then  dealing  with  each  separately  by 
suture.  Finally,  in  regard  to  stitching,  it  was  worth  noting  that 
Angus  Macdonald  had  used  Lembert's  suture,  but  applied  con- 
tinuously, and  this  had  one  great  advantage  over  Czerny's,  that  in 
cases  where  time  was  of  importance  it  could  be  applied  with 
greater  rapidity. 

Dr  Shaw  M'Laren  asked  if  Mr  Cotterill  could  confirm  Halsted's 
statement  that,  after  piercing  the  serous  and  muscular  coats,  the 
fibrous  layer  next  the  mucous  membrane  could  be  distinctly  felt 
against  the  point  of  the  needle.  He  also  desired  to  know  a  little 
more  particularly  as  to  the  distance  of  the  sutures.  He  thought 
it  might  be  possible  to  test  the  impermeability  of  the  sutured  gut 
to  the  passage  of  faeces  before  returning  it  to  the  abdomen. 

Mr  Duncan  had  on  a  few  occasions  the  opportunity  of  perform- 
ing operations  somewhat  similar  to  that  narrated  by  Mr  Cotterill, 
but  he  regretted  to  say  that  none  of  them  had  been  absolutely  suc- 
cessful. In  one  of  them  he  removed  the  gangrenous  portion  of 
bowel  in  a  strangulated  hernia,  sutured  the  gut,  and  returned  it  to 


1889.]  MEDICO-CHIRUEGIGAL   SOCIETY    OF    EDINBURGH.  659 

the  abdomen.     The  patient,  after  four  or  five  weeks,  died  of  a  per- 
fectly incontrollable  diarrhoea.     This  might  have  occurred  equally 
after  the  formation  of  an  artificial  anus.    In  another  instance  he  per- 
formed laparotomy  for  acute  obstruction,  and  found  a  small  sarcoma 
of  the  ascending  colon.     This  was  removed,  and  the  ends  of  the 
gut  sewn  together.    The  operation  was  one  of  extreme  difficulty,  the 
abdomen  being  large  and  fat,  and  the  depth  at  which  the  tumour 
lay  very  great.     It  was  not  successful ;  some  small  extravasation 
took  place,  and  the  patient  died  of  septic  peritonitis.     Eegarding 
the  question  what  they  should  do  with  the  bowel  in  strangulated 
hernia  after  removal  of  a  gangrenous  portion,  he  thought  that,  as 
shown  by  Mr  Cotterill,  the  formation  of  an  artificial  anus  was 
usually  better  than  the  immediate  suture  and  return  of  the  gut. 
What  were  they  to  do  with  this  artificial  anus  afterwards  ?     He 
thought  Mr  Caird  was  wrong  in  one  respect.     The  tendency  of 
faecal  fistula  to  heal  was  not  great  in  what  might  be  called  the 
second  stage.     Statistics  had  shown  that,  after   something   like 
eiglity  days,  there  was  almost  no  case  of  spontaneous  cure.    If  the 
possibility  of  spontaneous  cure  after  that  date  were  abandoned, 
liow  should  they  treat  the  artificial  anus  ?     Should  they  perform 
such  an  operation  as  that  done  by  Mr  Cotterill,  or  make  efforts  to 
render  the  passage  of  fasces  from  the  upper  part  of  the  bowel  to 
the  lower  more  easy  ?     Mr  Cotterill  indicated  specific  reasons  for 
adopting  the  plan  he  did  in  this  particular  case,  but  did  not  give 
tliem  a  sufficiency  of  detail.     His  position  was  that  the  obstruction 
to  the  passage  of  faeces  downwards  was  due  to  a  dragging  upon  the 
lower  part  of  the  bowel,  and  to  a  kink  at  the  splenic  flexure.    This 
appeared  hypothetical,  and  he  did  not  give  sufficient  reason  for  the 
performance  of  the  operation  when  he  was  not  certain  that  the 
lumen  of  the  bowel  would-be  open.  As  it  turned  out,  he  was  probably 
correct,  and  may  have  had  some  stronger  reason  than  he  gave  them 
for  believing  that  this  downward  dragging  was  the  cause  of  the 
obstruction.     Mr  Duncan  did  not,  however,  think  that  this  opera- 
tion was  the  correct  mode  of  treatment  for  artificial  anus  in  general. 
When  there  was  a  distinct  eperon,  the  first  thing  was  to  obliterate 
it.     The  septum  should  be   repressed,  whether   by  Dupuytren's 
method  or  by  the  twisting  with  a  wire.     In  cases  where  they  got 
the  passage  made  all  right,  but  the  fistula  refused  to  heal,  they 
might  adopt  a  method  he  had  recommended  twenty  years  ago,  and 
performed  on  two  occasions  with  complete  success.     This  consisted 
in  splitting  up  the  bowel,  and  sewing  mucous  membrane  inwards 
and  skin  outwards.     It  was  applicable  and  most  successful  in  rup- 
tured perineum  and  other  plastic  operations ;  and,  at  Mr  Chiene's 
suggestion,  he  liad  successfully  used  the  method  in  recto-urethral 
fistula  and  harelip. 

Mr  Miller  thought  the  success  of  Mr  Cotterill's  operation  was 
due  very  much  to  the  fact  that  it  was  done  h  deux  temps.  The 
faecal  fistula  was  first  formed,  and  after  preparing  himself  and  the 


660  MEETINGS   OF   SOCIETIES.  [jAN. 

patient  lie  carried  out  what  had  been  a  very  successful  proceeding 
for  its  closure.  Sometimes  it  was  necessary  to  perform  these  two 
in  one  operation.  In  these  circumstances  time  was  a  most  impor- 
tant element.  Senn  of  Milwaukee  recently  recommended  that  in 
such  cases  the  opening  in  the  bowel  might  be  occluded  by  a  flap  of 
omentum  and  putting  in  a  few  sutures  on  the  Lembert  principle. 
He  found  in  experiments  on  animals  that  this  was  perfectly 
successful  in  preventing  leakage  into  the  peritoneal  cavity,  and 
could  be  very  quickly  done. 

Mr  Gotterill,  replying,  said  he  preferred  clamping  the  gut  with  a 
metal  or  rubber  clamp  to  compression  with  the  fingers,  partly 
because  the  latter  were  in  the  way,  partly  because  in  a  long  operu- 
tion  they  could  not  be  trusted,  and  partly  because  their  heat  seemed 
to  have  an  injurious  effect  on  the  bowel.  He  thought  it  was 
possible  to  tell  when  the  needle  had  passed  through  the  serous  and 
muscular  coats.  These  slid  readily  upon  the  mucous  coat,  which 
he  did  not  think  he  had  pierced  once  with  the  needle  in  his 
experiments.  He  might  best  give  Dr  M'Laren  an  idea  of  the 
distance  of  the  sutures  from  one  another  by  informing  him  that  the 
sutures  in  any  one  row  were  about  a  line  apart  from  each  other, 
and  the  distance  between  the  outer  and  inner  rows  was  about  one- 
third  of  an  inch.  The  reason  why  he  had  adopted  the  operation  he 
did  in  this  case  was  because  of  the  position  of  the  portions  of  the 
bowel  presenting.  They  lay  parallel  to  one  another  outside  the 
abdomen,  separated  by  a  mass  of  fat  and  cicatricial  tissue.  There 
was  no  sort  of  attempt  at  passage  of  fseces  from  one  to  the  other. 
Water  injected  into  the  lower  portion  flowed  back  along  the  sides 
of  the  tube.  A  rectal  bougie  could  not  be  passed  towards  the 
rectum.  It  was  not  till  he  got  a  soft  oesophageal  bougie  past  the 
"  kink  "  that  fluids  passed  per  rectum,  but  after  that  obstruction 
was  overcome  large  quantities  flowed  easily.  He  considered  the 
septum  was  too  thick  to  be  attacked  by  any  of  the  ordinary  methods 
for  repression.  He  was  sure  that  these  operations  by  destroying 
the  spur  were  not  so  safe  as  was  sometimes  represented.  He  could 
not  agree  with  Senn's  recommendation  to  put  in  a  few  sutures,  and 
the  suggestion  to  test  the  imperviousness  of  the  sutin-ed  bowel  by 
allowing  the  passage  of  facal  matter  along  it  could  not  be  carried 
out  with  safety;  and,  moreover,  one  of  the  things  done  in  preparation 
of  the  patient  was  to  get  the  gut  thoroughly  washed  out.  If  this 
was  not  done,  and  faeces  allowed  to  escape  during  the  operation,  it 
was  a  very  difficult  matter  to  prevent  contamination  of  the  peri- 
toneal surface.  Mr  Gotterill  then  alluded  to  the  immunity  from 
risks  of  peritonitis  and  septic  absorption  which  were  constantly 
observed  in  patients  who  had  for  some  length  of  time  suffered  from 
old  hernia,  tumour,  or  other  abnormal  condition  of  the  abdomen. 
He  concluded  by  thanking  the  Society  for  the  extremely  kind  way 
in  which  they  had  received  his  paper. 


1889.]  OBSTETEICAL   SOCIETY   0¥   EDIKBUKGH.  661 

OBSTETRICAL  SOCIETY  OF  EDINBURGH. 

SESSION   L. — MEETING   I. 

Wednesday,  lAth  November  1888. — Dr  Underhill,  President,  in  the  Chair. 

I.  Dr  Sym  showed  a  malignant  growth  of  the  bladdeii.  The 
age  of  the  patient  was  73  from  whom  this  specimen  was  taken. 
She  was  first  under  the  hands  of  Dr  Angus  Macdonald  about 
four  years  ago  on  account  of  vesical  haemorrhage.  Afterwards 
she  came  into  Dr  Sym's  hands,  and  in  August  last  Dr  Halliday 
Croom,  on  his  behalf,  removed  some  papillomatous  growth 
from  the  vesical  wall.  She  improved  for  a  time  and  tlien  fell 
back ;  very  severe  pain  came  on  with  excessive  lia^morrhage,  and 
she  ultimately  died  in  the  end  of  October.  The  whole  posterior 
wall  of  tlie  bladder  is  occupied  by  a  carcinomatous  mass,  but  the 
ureters  and  neck  of  the  bladder  are  not  involved.  There  were  no 
secondary  growths  to  be  found,  but  there  are  two  fibroid  growths 
on  the  wall  of  the  uterus.  Dr  Henry  Alexis  Thomson  had  examined 
the  specimen,  and  said  that  it  was  one  of  rapidly  growing  cancer. 

II.  Professor  Simpson  showed  a  fcetus  which  presented  a  some- 
what rare  variety  of  deformity.  It  is  described  by  teratologists  as 
a  phocomelus,  and  is  sometimes  considered  as  a  result  of  intra- 
uterine rickets,  though  its  causation  is  not  always  due  to  this 
disease.  It  is  to  be  noted  that  all  the  extremities  are  deformed, 
though  the  exact  nature  of  the  deficiency  can  only  be  made  out  by 
dissection ;  sometimes  one  or  more  of  the  bones  of  the  limbs  are 
absent.  In  this  case  there  is,  besides,  a  deficiency  of  the  frontal 
bone,  and  the  orbital  cavities  are  thrown  widely  apart ;  no  doubt 
on  dissection  it  will  be  found  that  there  is  malformation  of  the 
base  of  the  skull.  The  aspect  of  the  foetus  had  changed  somewhat 
in  the  interval  since  its  birth,  but  a  fair  idea  of  its  appearance 
would  be  derived  from  the  sketch  which  had  been  made  soon  after 
delivery.  It  was  borne  by  a  woman  who  had  already  given  birth 
to  several  healthy  children,  and  there  was  no  evident  reason  why 
this  child  should  have  been  malformed.  It  was  a  head  presenta- 
tion, but  had  been  delivered  by  turning.  There  was,  as  is  so 
frequent  in  cases  of  malformation,  a  notable  amount  of  hydraranios. 
There  was  only  one  artery  in  the  umbilical  cord. 

III.  Dr  Sinclair  showed,  by  kind  permission  of  Mr  Symington, 
specimen  of  hydrometra.  This  was  taken  from  a  woman  aged  55 
years.  She  had  been  a  lunatic  for  the  last  o'd  years,  and  died  of 
purpura.  Dr  Sinclair  had  the  opportunity  of  having  her  under 
his  observation  during  the  last  four  years,  and  no  symptoms  pre- 
sented themselves  to  direct  his  attention  to  this  condition.  Mr 
Symington's  report  of  the  autopsy  was  as  follows  : — On  dissection 
of  perineum,  hymen  was  well  developed.     On  opening  peritoneal 


662  MEETINGS    OF   SOCIETIES.  [jAN. 

cavity,  an  organ  was  seen  in  pelvis  resembling  the  bladder.  Two 
small  irregular  openings  the  size  of  little  finger.  There  were  no 
signs  of  peritonitis  or  collection  of  tluid  in  peritoneum.  Cervix 
normal,  and  external  os  as  a  small  transverse  slit.  The  cervical 
canal  was  patent,  but  at  internal  os  a  fold  of  mucous  membrane 
appeared  to  cover  the  opening.  The  fundus  presented  the  appear- 
ance of  an  ordinarily  dilated  bladder,  and  was  of  the  capacity  of  a 
pint. 

IV.  The  President  read  his  introductoey  address,  which 
appeared  at  page  512  of  this  Journal. 

Professor  Sim2)son  proposed  a  cordial  vote  of  thanks  to  the 
President  for  his  able  address. 

V.  Dr  Mathcson  read  his  paper  on  a  case  of  rupture  of  the 
UTERUS,  which  will  appear  in  a  future  number  of  this  Journal. 

Professor  Simj)son  thought  the  Society  were  indebted  to  Dr 
Matheson  for  his  interesting  record  of  this  case  of  rupture  of  the 
uterus.  On  looking  at  the  preparation,  it  illustrated  well  the 
tendency  of  the  rupture  to  take  place  in  tlie  lower  segment  of  the 
uterus.  For  though  tlie  lower  part  of  the  Bandl  ring  had  been 
involved  in  the  laceration,  the  rent  ran  mainly  below  this,  and  ran 
not  merely  perpendicularly  but  also  transversely,  so  that  in  the 
anterior  wall  of  the  uterus  the  lower  segment  was  torn  through 
nearly  half  way  to  the  right  side.  Bandl  had  shown  that  face 
presentations  were  among  the  conditions  that  rendered  the  uterus 
liable  to  this  accident  under  its  own  efforts,  and  Dr  Matheson's 
case  showed  how,  in  the  effort  to  turn,  it  might  be  brought  about 
artificially.  Such  a  case  would  lead  us  to  believe  that  where  for- 
ceps fail  to  extract  the  child  after  the  lower  uterine  segment  has 
become  markedly  thinned,  it  will  be  safest  for  the  mother  to 
deliver  by  embryulcia. 

Dr  Freeland  Barbour  said  that  the  seat  of  the  rupture  in  this  case 
was  of  special  interest  with  regard  to  the  disposition  of  the  peritoneum 
on  the  pregnant  uterus.  Although  the  tear  extended  into  the  front 
wall,  it  was  chiefly  lateral — that  is,  over  a  part  of  the  wall  which  was 
not  covered  with  peritoneum.  In  the  sections  which  he  made  of  a 
case  from  the  first  stage  of  labour,  the  fact  which  struck  him  most 
was  the  absence  of  peritoneum  at  the  sides  of  the  uterus  within 
the  pelvis ;  while  the  peritoneum  in  front  and  behind  of  the  uterus 
retained  at  the  end  of  the  pregnancy  the  relations  of  the  non- 
pregnant condition,  that  at  the  sides  was  lifted  up  by  the  growing 
organ  so  as  not  to  descend  below  the  brim.  They  had  thus  a 
portion  of  uterus  which  was  embraced  by  cellular  tissue  only,  and 
if  the  tear  took  place  over  this  area,  it  went  into  cellular  tissue. 
They  had  thus  a  satisfactory  explanation  of  so-called  incomplete 
rupture,  and  one  which  was  more  intelligible  than  that  a  tear  should 
go  through  the  muscular  w^all  and  stop  short  at  the  delicate  peri- 
toneum. 


1889.]  OBSTETRICAL  SOCIETY   OF   EDINBURGH.  663 

The  President  said  this  case  illustrated  the  risks  which  were  in- 
herent to  the  operation  of  turning ;  they  might  perform  the  opera- 
tion ninety-nine  times  out  of  a  hundred  without  any  incident  to  cause 
them  anxiety.  And  then  came  a  case  where  some  untoward  accident 
happened — an  accident  which  might  have  occurred  spontaneously. 
The  tear  seemed  to  have  taken  place  in  the  usual  position,  and  the 
direction  of  the  rent  to  have  been  nearly  transverse.  These 
accidents  were  not  always  fatal.  He  had  once  to  induce  prema- 
ture labour  in  a  patient  who,  in  her  previous  labour,  had  had  a 
large  tear  in  the  uterus  or  vagina,  so  bad  that  coils  of  intestine 
had  come  down  into  the  vagina.  She  recovered,  however,  on  both 
occasions  without  any  bad  symptoms.  The  Society  were  much 
indebted  to  Dr  Matheson  for  bringing  forward  such  an  interesting 
subject  for  discussion. 

JDi'  Helme  said  the  Society's  thanks  were  due  to  Dr  Matheson 
for  so  fully  reporting  this  case.  It  illustrated  one  of  the  risks  of 
the  operation  of  turning  after  labour  had  been  going  on  for  some 
time,  and  the  lower  uterine  segment  had  become  drawn  out  and 
thinned  to  an  unusual  degree.  The  danger  of  rupture  of  the 
nterus  is  not  to  be  dreaded  before  this  stage  is  reached.  It  was 
surprising  what  amount  of  force  might  be  employed  within  the 
uterus  without  injury  when  there  was  no  morbid  thinning  of 
the  lower  segment.  The  risks  in  the  earlier  stage  might  be 
rather  on  the  part  of  the  foetus;  for  he  remembered  two  cases  of 
turning  which  occurred  in  the  Obstetrical  Klinik  in  Strassburg 
during  his  stay  there,  and  in  which  the  vertebral  column  of  the 
foetus  had  been  completely  fractured  without  evident  injury  to 
the  maternal  structures.  He  mentioned  this  to  point  out  the 
amount  of  force  it  was  possible,  though  by  no  means  advisable,  to 
employ  within  the  uterus  without  rupturing  it  when  there  was  no 
excessive  thinning  of  the  lower  segment.  In  Dr  Matheson's  case 
it  seemed  to  liini  that  the  rupture  was  to  be  explained  neither  by 
the  abnormal  presentation  nor  by  any  undue  force  employed,  but 
by  the  morbid  thinning  out  of  the  lower  segment. 

Dr  Matheson  quite  agreed  with  Prof.  Simpson's  remarks  as  to 
the  situation  of  the  rupture  in  the  specimen  before  the  Society, 
but  would  remind  him  that  the  description  in  his  paper  was  a 
clinical  one — it  described  the  rupture  as  felt  by  the  hand  within 
the  uterus  immediately  after  delivery,  when  strong  retraction  of 
the  uterine  muscle  existed.  The  fact  that  there  was  no  reason  to 
suspect  any  unusual  thinning  of  the  lower  uterine  segment,  and 
the  fact  of  the  child  being  alive,  decided  in  favour  of  version  as 
contrasted  with  embryulcia.  Dr  Barbour's  explanation  of  the 
non-rupture  of  the  peritoneal  covering  was  very  true,  and 
was  well  seen  when  the  post-mortem  examination  was  being 
made. 

VI.  Dr  Helme  read  his  paper  on  the  physiology  of  the  third 


664  MEETINGS   OF   SOCIETIES.  [jAN. 

STAGE:  A  CLINICAL  CONTRIBUTION,  wliich  appears  at  p.  612  of  this 
Journal. 

Professor  Simpson  regretted  tliat  Dr  Hart  had  not  been  able  to 
be  present  to  give  us  the  benetit  of  his  criticism  of  the  case  which 
Dr  Helme  had  laid  before  the  Society.  He  (Prof.  Simpson)  had 
expressed  himself  adversely  to  Dr  Hart's  explanation  of  the  mode 
of  separation  of  the  placenta  when  the  subject  was  under  discus- 
sion before,  and  his  belief  that  the  placenta  was  detached  during 
uterine  activity  was  greatly  confirmed  by  the  lucid  exposition 
which  Dr  Helme  had  made  of  his  interesting  case.  Only  he 
would  call  attention  to  the  circumstance  that  the  placenta  first 
expelled  was  that  wiiich  lay  lowest  in  the  uterus,  which  was  what 
might  be  anticipated  whatever  theory  might  be  entertained  as  to 
tlie  conditions  under  which  detachment  is  effected. 

Dr  Foulis  said  he  agreed  with  Prof.  Simpson  that  it  was  unfor- 
tunate Dr  Hart  was  not  present,  as  it  was  hardly  possible  to  make  any 
remarks  on  Dr  Helme's  interesting  paper  without  strongly  criticising 
Dr  Hart's  recently  published  views  on  the  separation  of  the  placenta. 
If  Dr  Hart's  theory  as  to  the  separation  of  the  placenta  was  correct, 
they  should  be  obliged  to  admit  that  the  relaxation  of  the  uterine  wall 
which  separated  the  placenta  was  an  active,  forcible  one.  Was  such  a 
relaxation  due  to  elasticity  or  to  resilience,  or  to  contraction  of  the 
uterine  muscular  wall  ?  Dr  Hart  denied  that  the  placenta  was 
separated  during  the  pains — that  is,  during  the  contractions.  He 
says,  "  the  placenta  is  separated  in  the  third  stage  after  the  pains," 
and  yet,  strange  to  say,  he  directs  us  "  when  the  child  is  born  to 
give  an  ergotine  injection  in  a  multipara,  at  any  rate,  if  the  labour 
has  been  slow."  From  what  they  knew  of  the  action  of  ergotin,  one 
would  have  thought  that  this  above  all  things  should  not  have 
been  given  if  the  separation  of  the  placenta  took  place  during  the 
relaxation  and  not  during  the  "  pains  "  of  the  uterus.  That  the 
elongated  muscular  fibres  shorten  and  contract  in  one  way  during 
the  powerful  contractions  of  the  uterine  wall  was  quite  certain,  but 
that  they  forcibly  elongate  or  contract  in  another  way  during 
relaxation  of  the  uterine  wall  was  not  only  not  proven,  but  was 
against  all  the  known  laws  of  physiology.  What  was  the  force  that 
produced  this  so-called  relaxation  of  the  uterine  wall  after  the 
contraction  was  over  ?  He  believed  that  this  act  of  relaxation  was 
entirely  passive,  and  that  it  was  caused  entirely  by  the  filling  and 
distension  of  the  sinuses  and  vascular  channels  in  the  wall  of  the 
uterus,  by  blood  poured  into  them  by  the  contractions  of  the  left 
ventricle  of  the  heart,  as  soon  as  the  contractions  of  the  uterus  itself 
were  over.  This  vascular  engorgement  and  consequent  relaxation  of 
the  uterine  muscular  wall  went  on  until  the  latter  was  stimulated  to 
contract  again.  The  act  of  relaxation  was,  comparatively  speaking, 
a  slow  one,  while  the  act  of  contraction  was  much  quicker  and  many 
times  more  powerful  than  the  act  of  relaxation.  It  seemed  to  him 
that  the  powerful  contractions  of  the  uterus  fully  explained  the 


1889.]  OBSTETUICAL   SOCIETY    OF    EDINBUKGH.  665 

separation  of  the  placenta.  After  the  child  was  born,  the  uterine 
wall  continually  diminishes  in  size,  and  the  area  of  its  placental 
attachment  must  be  greatly  reduced;  but  while  this  was  taking  place, 
the  size  of  the  placenta  was  but  slightly  reduced,  therefore  the  one 
must  be  separated  or  torn  from  the  other.  He  knew  nothing  more 
beautiful  in  physiology  than  the  free  circulation  of  the  blood 
around  the  chorionic  villi  as  they  hung  free  in  the  placental 
sinuses.  When  contractions  of  the  uterus  tear  through  the  attach- 
ment between  the  chorionic  villi  and  the  sinuses,  the  blood  in  the 
sinuses  begins  to  coagulate,  and  also  in  the  corresponding  parts  of 
the  placenta.  As  this  coagulation  takes  place  throughout  the 
substance  of  the  placenta,  it  gradually  becomes  harder  and  more 
resistent  in  its  substance,  and  thus  facilitates  its  own  separation 
from  the  uterus.  Dr  Helme's  paper  was  a  valuable  one,  and  he  was 
to  be  congratulated  on  its  excellence. 

Dr  Craig  said  he  entirely  corroborated  all  that  had  been  said  in 
praise  of  this  communication.  His  clinical  experience,  now  extend- 
ing over  twenty  years,  had  led  him  to  the  same  conclusion  as  that 
arrived  at  by  Dr  Helme.  His  universal  practice  was  to  grasp 
firmly  with  the  left  hand  the  uterus  through  the  abdomen  during 
the  completion  of  the  second  stage  of  labour.  And  after  the  birth 
of  the  child,  he  causes  the  nurse  to  grasp  tightly  the  contracted 
uterus,  and  to  hold  it  till  after  the  tying  of  the  cord  and  separation 
of  the  child.  Afterwards  he  seizes  the  contracted  uterus  and 
retains  hold  of  it  till  after  the  completion  of  the  third  stage  of 
labour.  By  this  simple  method  the  placenta  in  49  cases  out  of 
every  50  was  removed  within  five  minutes  of  the  birth  of  the  child. 
He  has  never  lost  a  case  from  post-partum  haemorrhage.  In  fact, 
he  believes  that  this  treatment  helps  to  separate  the  placenta  and 
to  throw  it  into  the  vagina,  and  tends  in  no  small  degree  to  prevent 
post-partuvi  haemorrhage. 

Di'  Freeland  Barbour  said  the  difficult  point  to  understand  in  Dr 
Helme's  extremely  interesting  case  was  why  the  second  placenta  was 
not  detached.  It  may  have  been  because,  being  aspirated,  its 
bulk  was  smaller,  and  so  did  not  present  so  large  a  mass  for  the 
uterus  to  act  on.  Its  attachment  also  over  the  fundus  may  have 
had  something  to  do  with  it ;  when  the  placenta  is  on  one  wall 
it  will  slip  down  more  easily,  and  the  detachment  and  slipping 
down  go  on  together. 

Dr  Thos.  Wood  said  they  were  greatly  indebted  to  Dr  Helme  for 
his  able  and  highly  instructive  paper.  It  contributes  greatly  to  the 
elucidation  of  this  much  discussed  question  of  how  the  placenta 
separates,  and  clearly,  he  thought,  shows  that  in  this  case,  at  least, 
separation  was  not  brought  about  by  the  relaxation,  but  by  the 
contraction  of  the  uterine  muscular  fibres.  The  following  case 
which  occurred  in  his  practice  some  time  ago,  and  which  had  some 
bearing  on  this  subject,  he  thought  worth  relating.  Mrs  H,  aged  29, 
multipara,  seven  months  pregnant,  was  taken  in  labour.     Just  as 

EDINBURGH   MED.    JOURN.,    VOL.    XXXIV. — NO.    VII.  4  P 


666  MEETINGS   OF   SOCIETIES.  [jAN. 

he  arrived  at  the  house,  and  before  he  had  seen  the  patient,  a  severe 
pain  came  on,  the  result  being  that  the  foetus  was  born  contained 
in  the  membranes  which  were  unruptured,  tlie  whole  thing  coming 
away  with  the  one  pain.  The  child  on  being  extricated  was  alive, 
and  lived  for  a  fortnight.  On  examination  of  the  placenta  there 
was  no  blood-clot  on  its  maternal  aspect  or  evidence  of  bleeding 
such  as  one  would  have  expected  to  get  had  there  been  any  separa- 
tion during  the  uterine  relaxation  preceding  the  last  contraction.  It 
would  thus  seem  that  the  last  pain  or  contraction  was  the  cause  of 
both  separation  and  expulsion. 

The  President  thought  Dr  Helme's  paper  an  admirable  one,  and 
he  regretted  Dr  Hart's  absence.  It  was  fortunate  the  case  had 
fallen  into  the  hands  of  one  who  was  so  competent  to  observe 
exactly  the  course  of  events,  and  to  reason  so  carefully  upon  them. 
He  believed  that  the  uterus  shed  the  placenta  in  consequence 
of  its  great  contraction,  the  lessened  placental  surface  in  the 
uterus  separating  from  the  placenta,  which,  when  pretty  full  of 
blood,  was  practically  non-compressible. 

Dr  Felkiii  said  he  had  heard  Dr  Helme's  paper  with  great  interest, 
as  it  fully  confirmed  the  view  he  took  with  regard  to  the  expulsion 
of  the  placenta.     Observation  of  parturient  women  in  uncivilized 
countries  had  convinced  Dr  Felkin  that  most  of  their  accidents  in 
child-bearing  were  due  to  the  retention  of  the  placenta,  and  he  had 
noticed  that  in  those  tribes  where  the  cord  was  either  bitten  or  cut 
through  with  a  blunt  instrument,  the  retained  placenta  less  fre- 
quently occurred  than  when  it  was  cut  with  a  sharp  knife  and  not  tied. 
Dr  Helme  thanked  the  Society  for  the  exceedingly  kind  manner 
in  which  his  paper  had  been  received.     He  also  regretted  Dr  Hart's 
absence.     Dr  Foulis  had  raised  an  important  question  as  to  the 
power  of  active  dilatation,  and  Dr  Helme  was  inclined  to  agree 
with  him  in  ascribing  a  very  important  part  to  the  blood  circula- 
tion.    In  reply  to  Dr  Barbour's  question.  Why  the  placenta  of 
the  first  child  did  not  separate  along  with  the  placenta  of  the 
second  child,  since  they  were  subjected  to  the  same  contraction, 
there  were  three  factors  which  influenced  this : — 1.  The  Mass  in 
the  Uterus. — When  both  placentae  were  present  there  was  a  large 
mass  on  which  the  weak  uterine  power  could  act.     This  power 
was  not  able  to  separate  both.     It  separated  the  one  and  not  the 
other  because  of  2  and  3.     2.  The  Condition  of  the  Bloodvessels. — 
The   one   placenta  was  emptied  of  blood  and  the  other  full  of 
blood.     As  the  uterus  becomes  smaller,  a  placenta  full  of  blood 
will  not  follow  the  diminution  in  area  of  its  site  to  the  same  degree 
as  a  placenta  which  contained  little  or  no  blood,  and  so  will  come 
to  be  stripped  ofif.     He  agreed  with  Dr  Felkin  on  this  subject. 
3.  The  Relative  Positions  of  the  Two  Placentce. — The  third  factor 
was  the  relative  position  of  the  two  placentse,  or  that  situated 
lowermost    separated    first.      During     separation     the    placenta 
first  begins   to  be  detached  at  its   lower   margin,  so   here   the 


1889.]  OBSTETRICAL   SOCIETY   OF   EDINBUEGH.  667 

placenta  situated  lowermost  was  first  separated.  With  regard  to  Dr 
Barbour's  other  question  as  to  whether  there  was  any  morbid 
adhesion  of  the  Last  placenta,  he  thought  certainly  not  on  these 
grounds — 1.  No  adhesions  were  felt ;  2.  The  separated  placenta 
had  a  normal  healthy  appearance ;  3.  The  child  was  healthy,  and 
born  at  full  time ;  4.  The  other  placenta  was  healthy  and  separated 
of  itself,  and  what  reason  was  there  that  the  uterus  should  develop 
in  its  interior  a  healthy  and  an  unhealthy  placenta  at  the  same 
time  ?  5.  The  placenta  was  partially  separated  at  its  lower  margin, 
and  if  the  contraction  had  been  powerful  enough  it  would  probably 
have  been  entirely  separated.  But  the  essential  point  is  that 
relaxation  failed  to  separate  both  the  placentae,  so  that,  even  if 
the  second  placenta  were  "  adherent,"  the  fact  still  remains  that 
relaxation  failed  to  detach  the  first. 


THE  GLASGOW  OBSTETRICAL  AND  GYNAECOLOGICAL 

SOCIETY. 

Wednesday,  'iSth  November  1888. — J.  Stuart  Nairne,  F.F.P.S.  Glasg.,  in  the 

Chair. 

Myoma  of  Uterus. — Dr  W.  L.  B-eid  showed  a  Myomatous  Polypus, 
recently  removed  with  the  galvanic  ecraseiir.  The  cervix  had  about 
a  month  earlier  been  divided  with  scissors  and  the  os  internum 
dilated,  a  method  of  procedure  he  had  frequently  found  effectual  in 
checking  haemorrhage.  The  myoma  soon  after  became  polypoid, 
and  was  easily  removed  with  a  new  and  simplified  Ecraseiir  which 
he  showed. 

Knotting  of  Umhilical  Cord. — 1.  Dr  M.  Cameron  showed  a  Coid 
so  tightly  knotted  as  to  cause  the  death  of  the  foetus.  2.  Dr  G.  A. 
Turner  showed  a  Cord  with  several  complicated  knots.  3.  Dr  Law- 
rence Oliphant  showed  Twin  Cords  firmly  tied  together  in  two  places. 
A  Committee  was  appointed  to  report  on  this  case,  as  some  of  the 
Fellows  were  sceptical  about  the  observation,  the  children  having 
been  born  in  the  street,  while  the  placenta  only  was  delivered  in 
Hospital.  Most  of  those  present  were  of  opinion  that  true  knots 
were  mucli  less  common  than  usually  said  to  be  in  the  text-books. 

Doubly  Flexible  Knee-joint. — Dr  G.  A.  Turner  described  a  Child 
born  with  one  knee-joint  doubly  flexible.  No  surgical  injury  could 
be  detected,  and  the  condition  had  entirely  disappeared  at  the  end 
of  six  weeks. 

President' s  Address  on  Oophorectomy. — The  President  tlien  delivered 
an  address  on  Lessons  in  Oophorectomy.  He  gave  an  abstract  of  50 
consecutive  cases,  full  details  of  which  he  was  publishing  in  a  work 
in  the  press.  He  detailed  several  cases,  and  described  his  pro- 
cedure. He  removed  only  the  diseased  ovary,  and  made  his  pedicle 
wherever  he  found  it  easiest  to  do  so  ;  in  certain  cases  he  merely 
punctured  small  cystic  ovaries,  and  returned  them  to  the  abdomen. 
One  patient  had  stated  she  was  unable  for  years  to  submit  to  inter- 


668  MEETINGS   OF   SOCIETIES.  [jAN. 

course,  and  it  was  eiglit  years  since  her  last  confinement.  She 
turned  out  to  have  been  pregnant  at  the  time  of  operation.  The 
case  did  well. 

ROYAL  MEDICAL  SOCIETY. 

N(w.  2Srd. — E.  C.  Carter,  M.B.,  in  the  chair.  E.  Ahernethj, 
M.B.,  delivered  his  Presidential  Address.  H.  H.  Littlejohn,  M.B., 
showed — (1.)  The  Kidneys  from  a  case  of  Phthisis.  The  left  was 
much  enlarged,  a  typical  example  of  tubercular  kidney,  and  ad- 
herent to  the  descending  colon  by  a  fibrous  attachment  the  size  of 
a  halfpenny  ;  the  right  kidney  M'as  no  larger  than  that  of  a  child 
of  one  year,  and  was  entirely  cystic.  (2.)  Heart  of  a  new-born 
infant,  showing  great  hypertrophy  of  the  left  ventricle.  (3.)  Heart 
of  a  woman  aged  72,  showing  a  thick  calcareous  bar  running  trans- 
versely to  the  wall  of  the  left  ventricle,  immediately  beneath  the 
outer  cusp  of  the  mitral  valve.  R.  E.  Horsley,  M.B.,  read  a  dis- 
sertation on  Chronic  Nasal  Catarrh. 

Nov.  30^/i.— H.  H.  Littlejohn,  M.B.,  in  the  chair.  E.  G.  Carter, 
M.B.,  delivered  his  Presidential  Address.  A.  R.  Stoddart,  M.B., 
communicated  the  case  of  a  woman,  aged  52,  admitted  to  Ward 
XVIL,  E.  E,  L,  deeply  jaundiced  and  very  emaciated.  Two  years 
previously  she  had  suffered  from  constant  vomiting,  relieved  by 
the  usual  remedies.  Eighteen  months  previously  she  felt  pain  in 
the  right  hypochondriac  and  lumbar  regions  ;  and  six  months  later 
a  tumour  was  noticed  in  the  right  hypochondriac  region.  Three 
months  previous  to  admission,  jaundice,  at  first  intermittent,  but 
latterly  persistent,  appeared.  Blood  had  been  noticed  in  the  stools 
for  eighteen  months.  The  tumour,  on  examination,  appeared  to 
measure  about  6  inches  by  3|  inches,  and  just  internal  to  it  was 
felt  a  nodule  half  the  size  of  a  walnut,  freely  movable,  soft,  and 
deeply  seated.  Shortly  after  admission,  patient  died  of  peritonitis. 
The  specimens,  which  were  exhibited,  showed  an  enormously 
dilated  gall-bladder  and  common  duct.  The  latter  was  as  large  as 
the  small  intestine.  A  malignant,  f ungating,  and  ulcerated  growth 
was  found  in  the  duodenum  at  the  point  of  entrance  of  the  bile 
duct.  The  cause  of  the  peritonitis  was  not  discovered.  IT.  H.  Little- 
john, M.B.,  showed — (1.)  The  Stomach  from  a  case  of  Oxalic  Acid 
Poisoning,  in  which  half  an  ounce  was  taken,  and  death  resulted 
in  twenty  minutes.  (2.)  Specimens  from  a  case  of  Suicide  with  a 
Pistol ;  the  bullet  traversed  the  left  lung,  aorta,  right  auricle,  and 
right  lung.  (3.)  The  Stomach  of  a  Child  tightly  distended  with 
flatulence,  which  had  probably  caused  death  by  impediment  to 
respiration.  Jas.  Ritchie,  M.B.,  read  a  dissertation  on  the  Occur- 
rence of  Fits  as  a  Symptom  of  Disease. 

Dec.  7th.— B..  H.  Littlejohn,  M.B.,  in  the  chair.  IT.  H.  Little- 
john, M.B.,  showed  a  well-marked  specimen  of  Villous  Cancer  of 
the  Pylorus,  from  a  woman  aged  52 ;  and,  on  behalf  of  A.  L.  Gil- 
lespie, M.B.,  a  specimen  of  Advanced  Mitral  Stenosis.    A.  J.  Whiting 


1889.]  ROYAL  MEDICAL   SOCIETY.  669 

gave  a  communication  on  a  case  of  Transposition  of  the  Viscera,  oc- 
curring in  a  woman  who  was  admitted  to  the  Eoyal  Infirmary,  under 
Professor  Eraser's  care,  for  symptoms  of  cardiac  disease.  Atten- 
tion was  first  directed  to  the  abnormality  by  palpitation  on  the  right 
side  during  lactation.  Physical  examination  revealed  the  presence 
of  mitral  stenosis,  and  the  fact  that  the  abdominal  viscera,  as  well 
as  the  heart,  were  transposed.  The  family  history  was  of  rheu- 
matism, but  no  evidence  could  be  elicited  of  similar  abnormality 
in  other  members  of  the  family,  several  of  whom  came  under 
observation.  The  cause  of  this  abnormality  had  not  been  fully 
made  out ;  but  observation  in  the  case  of  the  chicken  seemed  to 
point  to  rotation  of  the  embryo  on  the  yolk  sac  to  the  right,  instead 
of  to  the  left,  as  a  usual  accompanying,  if  not  actually  causal  con- 
dition.    G.  W.  Sanders  read  a  dissertation  on  Death. 

Dec.  lUh. — A.  L.  Gillespie,  M.B.,  in  the  chair.  G.  0.  C.  Mackness, 
M.B.,  gave  a  communication  on  three  cases  of  Bright's  Disease  with 
complications.  The  first,  a  man  admitted  to  Ward  VI.,  E.  K.  I., 
unconscious,  after  a  heavy  drinking  bout,  displayed  paresis  of  the 
right  side  of  the  face,  rigidity  of  the  right  arm  and  leg,  and  conju- 
gate deviation  of  the  eyes  to  the  left.  Breathing  was  rapid  and 
stertorous.  Later,  convulsive  movements  were  observed  on  the 
right  side.  Urine  drawn  off  by  catheter  contained  a  large  amount 
of  blood  and  albumen.  Patient  died  six  hours  after  admission, 
during  which  time  the  temperature  had  risen  from  99°"8  F.  to 
103°'4  F.  On  post-mortem  examination  diffuse  purulent  menin- 
gitis was  all  that  was  found  in  the  head  to  account  for  the  symp- 
toms. The  second  case  was  that  of  a  woman  admitted  to  Ward 
XXV.  in  a  very  debilitated  condition.  She  had  been  a  heavy 
drinker.  Nervous  symptoms  were  not  at  all  prominent,  though 
she  wandered  occasionally.  On  post-mortem  examination  a  leathery 
false  membrane  was  found  on  the  under  surface  of  the  right  half  of 
the  dura  mater.  The  third  case,  also  alcoholic,  exhibited  somewhat 
similar  clinical  features,  but  no  cerebral  lesion  was  discovered  on 
post-mortem  examination.  W.  G.  Sym,  M.B.,  read  a  communica- 
tion on  the  Action  of  the  External  Ocular  Aluscles  and  the  Diag- 
nosis of  their  Paralytic  Conditions.  G.  W.  A.  Robertson,  M.B.,  read 
a  dissertation  on  the  Physiognomy  in  Disease. 


I^att  jTouvtl), 


PERISCOPE. 

MONTHLY  REPORT  ON  THE  PROGRESS  OF  THERAPEUTICS. 

By  William  Craig,  M.D.,  F.R.S.E.,  Lecturer  on  Materia  Medica,  Edinburgh 
School  of  Medicine,  etc.,  etc. 

Treatment  of  Aneueism. — According  to  the  Paris  correspondent 


670  PEuiscorE.  [jax. 

of  the  Lancet  (September  1,  1888),  at  a  recent  meeting  of  the 
Academy  of  Medicine,  Dr  Dnjardin-Beaumetz  read  a  note  from 
Professor  Germain  See,  wiio  was  unavoidably  absent.  The  note  is 
composed  of  three  parts.  Tiio  first  is  relative  to  a  curious  coincid- 
ence of  the  presence  of  bacilli  in  aneurisms,  and  the  others  treat  of 
the  methods  of  internal  treatment.  This  work  is  the  result  and  the 
rlsume  of  observations  collected  during  a  great  number  of  years, 
and  comprises  twenty-ibur  cases  which  were  regularly  followed 
during  a  long  space  of  time  ;  all  the  others  have  no  value,  as  they 
were  lost  sight  of.  Professor  S^e  observes  that  there  is  a  singular 
coincidence  of  aneurism  with  pulmonary  phthisis,  and  puts  the 
question,  Wiiether  it  is  by  the  parietes  of  the  aorta  that  the  bacillus 
penetrates  the  aneurism — a  question  which,  he  said,  he  was  not  in  a 
position  to  answer  satisfactorily.  In  any  case, this  interesting  observa- 
tion of  the  phthisis  of  aneurismal  subjects  remains  a  scientific  fact.  In 
the  second  part  of  his  work,  M.  S^e  deals  with  aneurisms  and  their 
treatment  by  iodide  of  potassium  and  anti])yrin,  the  good  effects  of 
which  in  these  cases  Dr  Dujardin-Beaumetz  said  he  was  able  from 
his  own  experience  to  confirm.  After  iiaving  established  the 
physiological  action  of  iodine  on  data  of  the  most  positive  clinical 
experience,  M,  S^e  draws  a  curious  parallel  between  the  two  iodides 
commonly  in  use.  He  demonstrates  that  iodide  of  sodium  is  a 
theoretical  medicament,  and  is  not  equal  to  the  iodide  of  potassium, 
which  is  manifestly  superior  to  it  in  maladies  of  the  heart  and  the 
vessels,  precisely  because  in  small  doses  the  salts  of  potash  act, 
according  to  Traube,  in  the  most  distinct  manner  on  the  musculo- 
motor  system,  and  even  on  the  inhibitory  nerves  of  arrest  of  the 
heart,  whereas  it  is  only  toxic  when  employed  in  subcutaneous  in- 
jections in  strong  doses.  Iodide  of  potassium,  when  ingested,  never 
becomes  toxic,  even  in  doses  of  10  or  15  grammes  per  day ;  any 
toxic  effects  produced  are  to  be  attributed  to  the  iodine,  and  not  to 
the  potassium.  The  third  part  of  the  work  is  relative  to  the  simul- 
taneous employment  of  antipyrin  with  iodide  of  potassium.  Accord- 
ing to  Professor  See,  antipyrin, far  from  having,  as  believed  by  certain 
medical  men,  a  pernicious  influence  on  the  heart,  lias,  on  the  contrary, 
the  most  remarkable  effects  on  the  central  organ  of  the  circulation. 
It  calms  the  impulsion  of  the  heart,  which  is  exaggerated  in  aneur- 
ismal subjects,  and  permits  the  blood  to  complete  its  coagulation, 
which  singularly  favours  the  cure.  But  the  most  remarkable  effect 
of  antipyrin  is  this :  the  greater  number  of  aneurismal  subjects  ex- 
perience at  the  arch  of  the  aorta  and  in  the  heart  sharp  pains, 
painful  cardiac  oppression,  and  very  often  sensations  of  anguish, 
exactly  as  in  angina  pectoris ;  antipyrin  dissipates  all  these  painful 
and  dangerous  symptoms.  Dr  Dujardin-Beaumetz  concurs  with 
Professor  S^e  as  to  the  good  effects  of  antipyrin,  but  he  very  much 
prefers  phenacetine,  as  the  former,  when  administered  for  any  length 
of  time,  produces  nearly  always  cutaneous  eruptions,  whereas  this 
cannot  be  said  of  phenacetine,  which  never  occasioned  untoward 


1889.]  MONTHLY    UEPOllT   ON   THERAPEUTICS.  671 

symptoms,  even  wlien  given  for  months  in  large  doses.  It  is  equally- 
preferable  to  iedanilide,  which  produces  cyanosis,  in  fine,  phen- 
acetine  is  not  toxic.  Dr  Dujardin-Beauiuetz  was  able  to  administer 
to  an  animal  as  much  as  3  and  4  grammes  ])er  kilogramme  of  its 
weight  without  observing  any  accident.  The  only  inconvenience 
of  phenacetine  is  its  not  being  very  soluble  ;  it  is  necessary  to 
administer  it  in  wafers ;  but  its  analgesic  effects  are  obtained  with 
a  dose  of  half  the  amount  of  that  of  antipyrin.  Dr  Dujardin- 
Beaumetz,  like  Professor  8ee,  condemns  all  surgical  interference  in 
the  treatment  of  aneurisms  of  the  aorta. — Therapeutic  Gazette, 
October  1888. 

SuLPHONAL. — In  the  British  Medical  Journal  for  8th  December, 
Dr  J.  Mason  Windermere  says,  "  I  have  found  it  very  useful  in  an 
obstinate  case  of  insomnia.  The  patient  is  a  gentleman  over  70, 
who  has  frequently  for  months  at  a  time  suffered  from  sleeplessness. 
He  has  used  every  drug  of  repute,  both  new  and  old,  but  none  ex- 
cept sulphonal  have  given  him  natural  sleep,  and  all  with  after  effects 
so  unpleasant  as  to  necessitate  their  discontinuance.  He  has  taken 
sulphonal  in  twenty-grain  doses  twice  a  week  or  so  for  many  weeks  ; 
it  has  never  failed  to  procure  three  or  four  hours  sleep,  and  he 
observes  that  he  is  rather  drowsy  next  day,  and  sleeps  soundly  the 
following  nigiit,  and  generally  the  night  after  as  well." 

CONDURANGO  IN  THE  TREATMENT  OF  CaKGINOMA  OF  THE 
Stomach. — The  treatment  of  cancer  by  condurango  (the  bark  of 
Gonolohus  condurango,  Eichard,  or  Marsdenia  condurango.  Brown, 
an  Asclepiadacea  indigenous  in  Ecuador  and  Peru,  especially  in  the 
Peruvian  province  of  Loja),  which  at  its  first  introduction  by  Fried- 
reich in  1874  had  been  hailed  with  so  much  expectation,  soon  fell 
into  oblivion.  Lately,  however,  it  was  submitted  to  a  methodical 
investigation,  first  by  Immermann  in  a  limited  mumber  of  cases, 
and  by  Riess  in  a  larger  number  of  specific  character,  wiiich  have 
recently  been  published.  Riess  wishes  to  limit  the  use  of  this  remedy 
entirely  to  the  treatment  of  carcinoma  of  the  stomach,  and  from  his 
experiences  in  eighty  cases  treated  with,  and  in  one  hundred  and 
sixteen  cases  treated  without,  condurango,  pronounces  for  its  specitic 
action.  "  The  observation,"  he  maintains,  "  of  a  greater  series  of 
cases  produced  the  conviction  that  the  lives  of  many  patients  had 
been  considerably  prolonged  by  the  condurango  treatment. 
Orszewcky  and  Erichsen  state  that  the  use  of  condurango  bark 
stimulates  the  development  of  connective  tissue,  and  at  the  same 
time  the  disintegration  of  the  cellular  elements  of  the  cancer." 
Professor  Ewald  [London  Medical  Recorder,  August  20,  1888) 
does  not  deny  the  favourable  effect  of  condurango  on  the  general 
condition  of  patients  suffering  from  carcinoma  of  the  stomach. 
"  With  good  reason,"  he  says, "  and  in  consequence  of  the  important 
observation  of  Riess,  the  condurango  is  at  present  extensively 
employed.     It  improves  the  concomitant  gastric  catarrh,  and  having 


672  PERISCOPE.  [JAN. 

the  same  favourable  effect  in  general  nriuco-catanlial  (lisease.s  of  the 
mucous  membrane  of  the  stomach,  the  condurango  proves  an 
excellent  stomachic  in  all  the  ca.ses  in  wliich  there  is  a  genuine 
catarrii  of  the  mucous  membrane,  i.e.,  the  secretion  of  a  rnuco-serous 
more  or  less  purulent  fluid." — Therapeutic  Gazette,  November  1888. 

Glycerine  Enemata  in  Constipation. — In  the  Hospital  Gazette 
for  10th  November,  Dr  James  D.  Staple  says  he  has  "  given 
glycerine  injections  over  one  hundred  times.  The  quantity  injected 
was  one  drachm  for  children  and  two  drachms  for  adults,  in  a  specially 
constructed  syringe.  The  bowels  acted  generally  within  fifteen 
minutes ;  in  some  rare  cases  half-an-hour  elapsed,  and  on  two 
occasions  the  injections  had  to  be  repeated.  The  entire  absence  of 
pain,  and  the  ease  with  which  they  may  be  administered, — patients 
being  able  to  give  the  enemata  to  themselves, — the  rapidity  of  their 
action  and  the  absence  of  any  griping  following,  give  them  a  distinct 
advantage  over  aperient  medicines  administered  by  tiie  mouth, 
which  sometimes  are  so  objectionable  to  the  patient  and  not  so  rapid 
in  their  action." 

OCCASIONAL  PERISCOPE  OF  THE  DISEASES  OF 
CHILDREN. 

By  Charles  E.  Underhill,  M.B.,  F.R.C.P.E.,  Physician  to  the  Royal 
Hospital  for  Sick  Children. 

Typhoid  Fever  in  Infancy. — This  disease  has  been  known 
to  occur  in  infants  during  the  first  few  weeks  of  life,  but  it  is 
certainly  rare  under  six  months.  Boys  seem  more  liable  to  it  than 
girls.  As  a  rule  it  is  less  severe  and  considerably  shorter  in  dura- 
tion in  the  young  than  in  adult  life.  Diarrhoea' is  far  less  common, 
the  temperature  does  not  run  so  high,  tympanitis  is  not  so  marked, 
and  the  rash  is  frequently  absent.  Epistaxis  is  rare  in  childhood, 
and  haemorrhage  from  the  bowels  is  both  less  frequent  and  of  less 
grave  import.  The  spleen  is  very  frequently  enlarged.  The 
nervous  symptoms  are  less  intense  in  infants  than  in  later  years. 
Among  the  complications,  bronchitis  is  frequently  met  with,  some- 
times in  a  severe  form,  and  croupous  pneumonia  is  not  very  rare. 
Gangrene  of  the  mouth  occasionally  follows  severe  cases ;  perfora- 
tion of  the  bowel  is  very  rare.  The  prognosis  is  niucli  more 
favourable.  The  treatment  is  to  be  guided  largely  by  common 
sense.  Fluid  food,  cool  sponging,  avoidance  of  excess  of  feeding, 
and  careful  attention  to  tlie  bowels  are  the  chief  indications. — J. 
M.  Keating,  M.D.,  Arch,  of  Pcediat.,  June  1888. 

Cases  of  Congenital  Stenosis  of  the  Pylorus  observed  in 
Children. — There  is  a  form  of  stenosis  of  tiie  pylorus  occasionally 
found  in  adults,  where  the  opening  is  simply  exceedingly  small, 
without  any  thickening  of  the  walls  or  organic  change  of  any  kind. 
This  has  been  assumed  to  be  congenital.     If  that  be  so  we  ought 


1889.]     OCCASIONAL  PERISCOPE  OF  THE  DISEASES  OF  CHILDREN.         673 

to  observe  the  same  condition  in  children.  Hitherto  such  observa- 
tions have  not  been  published,  although  strictures  of  other  parts  of 
the  intestinal  canal,  such  as  the  duodenum,  ileum,  large  intestine, 
and  anus  have  been  frequently  noted.  Hirschsprung  in  this  paper 
supplies  the  want  and  relates  two  cases.  In  case  1  an  infant  born 
apparently  healthy  and  well  grown  died  on  the  30th  day  of  collapse. 
The  symptoms  were  frequent  vomiting  and  small  and  infrequent 
stools;  there  was  no  bile  in  the  vomited  matters;  the  child  was  fed 
entirely  on  the  breast.  A  sectio  showed  the  stomach  to  be  distended 
and  its  walls  thickened ;  the  pyloric  portion  formed  a  firm 
cylindrical  thickening,  about  an  inch  in  length,  and  with  a  lumen 
only  wide  enough  to  allow  a  small  sound  to  pass.  The  thickening 
was  most  marked  in  the  muscular  layer,  but  there  was  also  an 
hypertrophy  of  the  mucous  membrane.  In  the  second  case  the 
child  died,  at  the  age  of  six  months,  of  tuberculosis,  after  having 
suffered  from  vomiting  in  a  less  severe  degree  than  case  1.  A 
somewhat  similar  condition  of  the  stomach  and  pylorus  was  found 
post-mortem.  The  stomach  was  somewhat  dilated,  the  muscular 
and  mucous  layers  being  thicker  and  harder  than  is  normal. 
Towards  the  pyloric  end  this  thickening  increased,  but  there  was  a 
well-marked  boundary  between  it  and  the  pylorus  itself,  which  was 
greatly  thickened  and  hypertrophied.  Its  lumen  was  very  narrow, 
but  not  to  the  same  extent  as  in  the  first  case.  The  child  might 
have  lived  and  grown  up,  so  far  as  the  narrow  pylorus  was  concerned. 
— Jahrhuch  f.  Kinderheilk.,  B.  xxviii.  H.  1. 

On  Febrile  Albuminuria  in  Childhood. — From  observations 
on  a  number  of  cases  of  typhus  and  typhoid  in  hospital,  the  author 
comes  to  the  following  conclusions : — 1.  Typhous  albuminuria  is 
of  very  common  occurrence,  and  is  observed  in  three-fourths  of  all 
the  cases.  2.  The  albuminuria  begins  most  frequently  in  the  first 
week,  and  even  in  the  first  days  of  the  disease.  3.  The  duration  of 
the  albuminuria  cannot  be  accurately  determined ;  it  lasts  from  a 
week  to  ten  days.  4.  The  frequency  of  typhous  albuminuria  and 
the'quantity  of  albumen  which  is  discharged  stand  in  close  relation- 
ship with  the  intensity  of  the  fever  and  its  duration. — Alex.  Ekkert, 
L.C. 

A  Case  of  Tumours  of  the  Cerebellum  and  Pons  Varolii. 
— The  subject  of  this  paper,  a  child  of  thirteen  months,  was  struck 
on  the  seventh  cervical  vertebra  by  a  hard  leather  ball.  There 
was  a  strong  tubercular  history.  He  recovered  shortly  from  the 
accident,  but  six  months  later  both  legs  became  weak,  a  discharge 
began  from  the  right  ear,  the  right  side  of  the  face  became  paralyzed, 
and  there  was  internal  strabismus  of  the  right  eye.  A  year  after 
the  accident  he  was  first  seen  by  the  author,  who  found  the  right 
eye  permanently  open,  turned  inwards,  and  the  seat  of  a  corneal 
ulcer.  He  could  stand  on  his  feet  but  could  not  walk ;  there  was 
vomiting  without  nausea  every  morning  on  waking  and  frequently 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    VII.  4   Q 


674  PEiascoi'E.  [jan* 

during  the  day ;  he  was  fretful  and  emaciated,  and  seemed  to  have 
headache.  The  optic  nerves  were  apparently  normal.  There  was 
some  general  hypersesthesia;  he  generally  lay  quiet,  but  was  fretful 
when  moved  ;  temp.  99°'6.  He  was  taken  away  by  tlie  mother,  and 
died  six  months  later  greatly  emaciated.  A  section  imperfectly 
made,  owing  to  objections  on  the  part  of  the  parents,  showed  three 
tumours:  one  protruding  from  the  right  side  of  the  cerebellum  at 
the  point  of  entrance  of  the  middle  peduncle  and  a  little  posterior 
and  inferior  to  it;  it  was  firmly  adherent  to  the  dura  mater  in  the 
cerebellar  fossa,  and  compressed  the  seventh  and  auditory  nerves. 
The  second  was  on  the  same  side,  and  was  in  the  centre  of  the  pons 
varolii.  The  third  was  on  the  opposite  side  of  the  brain,  in  the 
outer  layer  of  the  lenticular  nucleus.  The  brain  tissue  surrounding 
them  was  not  softened;  they  varied  in  size,  but  were  about  three- 
fourths  of  an  inch  in  diameter.  No  microscopic  examination  was 
permitted.  A  resume  is  given  of  a  number  of  similar  cases  quoted 
from  various  authors. —  J.  Lewis  Smith,  M.D,,  Arch,  of  Pcediat., 
May  1888. 

A  Kesume  of  Eecent  Views  concerning  Icterus  Neonatorum, 
AND  ITS  RELATION  TO  Sepsis. — From  the  opinions  of  many  recent 
writers  whose  views  are  briefly  considered,  it  is  evident  that  while 
some  forms  of  icterus  are  due  to  mechanical  causes,  i.e.,  are  of  hepa- 
togenous origin,  others  are  due  to  chemical  or  hsematogenous 
causes.  There  is  no  theory  which  will  apply  uniformly  to  all 
cases.  In  the  great  majority  of  cases,  where  there  is  merely  the 
discoloration  of  the  skin  and  mucous  membranes,  there  is  no  sepsis  ; 
the  functions  are  properly  performed,  the  faeces  are  of  yellow  colour, 
and  the  urine  without  bile  pigments.  The  condition  is  then  merely 
a  hgemoglobinEemia,  which  is  physiological  within  certain  limits. 
In  other  cases  where  the  icterus  is  more  profound,  the  faeces  nearly 
or  quite  without  bile,  and  the  urine  containing  bile  pigments  and 
bile  acids,  the  evidences  of  constitutional  affection  are  more 
pronounced,  and  there  is  present  undoubtedly  hsemoglobingemia,  or 
cholsemia,  or  toxaemia,  but  no  evidence  of  sepsis  or  septic  infection. 
The  umbilicus  is  healthy,  and  there  are  none  of  the  ordinary 
symptoms  of  phlebitis,  though  the  cases  may  go  on  to  a  fatal  issue. 
These  cases  may  depend  on  non-closure  of  the  ductus  venosus, 
malformations,  weakness  of  the  heart,  pulmonary  atelectasis,  and 
other  causes  which  lead  to  insufficient  tension  in  the  portal  vein, 
with  consequent  stasis,  effusion  of  bile,  and  subsequent  resorption. 
In  the  third  class  of  cases  there  are  distinct  evidences  of  septic 
poisoning.  The  skin  may  or  may  not  be  very  yellow;  there  is 
great  constitutional  disturbance,  high  temperature,  dry  tongue, 
tender  and  swollen  belly,  ulcerated  and  purulent  umbilicus,  and 
there  may  be  chills  and  abscesses  in  the  parenchyma  of  the  tissue 
or  elsewhere.  Such  cases  seldom  live  beyond  the  nineteenth  day. 
This  is  the  icterus  malignus  of  some  writers ;  and  Birch-Hirschfeld 


1889.]      OCCASIONAL  PERISCOPE  OF  THE  DISEASES  OF  CHILDREN.         675 

has  found  both  rod-shaped  and  spherical  bacteria  in  the  discharges 
from  the  umbilicus.  Thus  broad  distinctions  must  be  drawn 
between  those  cases  of  icterus  which  are  caused  by  an  excess  of 
hsemoglobin  in  the  blood,  those  which  are  due  to  a  resorption  of  bile, 
and  those  which  result  from  septic  elements  and  conditions. — Arch, 
of  Pcediat,  May  1888. 

The  Quantity  of  Haemoglobin  in  the  Blood  of  Children 
IN  Hkalth  and  Disease. — This  valuable  paper  contains  tlie 
record  of  a  very  large  number  of  observations  on  this  subject  made 
with  V.  Fleischl's  htemometer.  The  amount  of  ha3moglobin  was 
estimated  relatively,  not  absolutely — the  blood  of  a  healthy  man 
between  25  and  30  being  taken  as  the  standard.  As  regards  healthy 
children,  the  individual  variations  were  found  to  be  too  great  to 
deduce  from  them  any  definite  average  values  for  different  ages ; 
the  records  are  given  for  what  they  are  worth.  It  can  be  positively 
stated,  however,  that  when  the  amount  sinks  below  60  per  cent,  the 
child  is  not  in  good  health.  But  in  disease  continuous  observations 
made  during  the  whole  course  of  the  illness  are  of  great  interest, 
and  bring  out  some  more  definite  results.  Thus  in  uncomplicated 
scarlatina  the  amount  of  haemoglobin  was  high  at  the  commencement 
of  the  disease,  decreased  slowly  during  tiie  course  of  the  illness, 
and  increased  again  during  convalescence,  but  never  reached  the 
same  height  as  at  first.  In  complicated  cases  (nephritis,  etc.) 
the  course  was  irregular;  in  several  cases  there  was  a  great  fall  in 
the  haemoglobin  just  before  the  outbreak  of  the  nephritis.  Again, 
in  uncomplicated  measles  (13  cases)  the  results  were  similar,  a  fall 
in  haemoglobin  after  the  temperature  reached  the  normal,  followed 
by  a  slow  rise  during  convalescence,  until  it  eventually  reached  the 
same  height  as  at  the  beginning  of  the  disease.  In  complicated 
cases  (pneumonia,  etc.)  the  amount  of  haemoglobin  varied  very 
irregularly,  and  no  law  could  be  deduced  from  them.  In  croupous 
pneumonia  the  same  law  as  above  holds  good, — a  fall  in  amount 
coming  on  with  the  crisis,  slowly  to  rise  again  during  the  end  of 
convalescence.  It  might  have  been  expected  that  with  the  increased 
discharge  of  fluids  from  the  skin  and  kidneys  which  occurs  after  the 
crisis,  without  any  material  increase  in  the  quantity  taken  as  food, 
the  blood  would  become  more  concentrated,  and  the  haemoglobin 
would  consequently  rise  in  amount;  but  this  is  not  the  case:  the 
most  probable  explanation  being  that  there  is  a  great  resorption  of 
fluid  from  the  perivascular  spaces  and  tissues  generally.  Similar 
investigations  were  carried  on  in  relation  to  other  diseased  conditions, 
such  as  bronchitis,  tuberculosis,  meningitis,  atrophy,  and  rickets, 
and  the  paper  concludes  with  some  interesting  notes  on  the  effects 
which  fever,  from  whatever  cause,  has  upon  the  amount  of  haemo- 
globin in  the  blood. — J.  Wielowitz,  Jahri.  f.  Kinderheilk.,  B. 
xxviii.,  H.  1. 


676  MEDICAL   NEWS.  [jAN. 


MEDICAL    NEWS. 


SIR  MORELL  MACKENZIE  ON  THE  TREATMENT  OF  ACUTE 
AND  CHRONIC  TONSILLITIS. 

Reported  by  J.  Maxwell  Ross,  M.B, 

Os  Tuesday,  December  4th,  Sir  Morell  Mackenzie  visited  the 
throat  clinic  at  the  Edinburgh  Eye,  Ear,  and  Throat  Hospital. 
He  examined  a  number  of  the  patients,  and  in  the  course  of  a  short 
clinical  lecture  made  the  following  remarks : — 

There  are  two  forms  of  acute  tonsillitis,  the  superficial  and  the 
deep.  All  of  you  must  be  well  acquainted  with  these  familiar 
diseases,  but  perhaps  you  will  like  to  hear  my  experiences  of  the 
treatment.  The  superficial  is  not  very  serious.  It  is,  however, 
painful,  and  it  is  apt  to  recur.  A  person  who  has  had  it  once  is 
very  likely  to  have  it  again.  This  is  true  of  both  forms  of  tonsil- 
litis, but  is  particularly  so  of  the  superficial.  The  interior  of  the 
follicles  becomes  inflamed  and  secretes  an  unhealthy  mucus,  and 
they  never  thoroughly  recover.  In  all  inflammations  of  mucous 
membranes  the  membrane  does  not  really  get  well,  though  it  may 
appear  to  do  so.  A  celebrated  French  surgeon  has  said  that  he 
does  not  believe  that  a  person  ever  really  recovers  after  a 
gonorrhoea.  This  is  true  of  the  follicles  of  the  throat.  A  person 
who  has  once  had  acute  tonsillitis  never  really  gets  well,  though 
he  may  appear  to  do  so.  The  treatment,  therefore,  is  important. 
One  of  the  most  popular  remedies  is  aconite — originally,  I  believe, 
a  homoeopathic  drug,  but  now  used  extensively  by  allopatlis  (though 
I  object  to  the  term) — and  strongly  recommended  by  Dr  Einger. 
It  has  certainly  never,  in  my  hands,  proved  to  be  of  the  extra- 
ordinary value  which  he  asserts.  On  the  other  hand,  I  have  found 
guaiacum,  which  used  to  be  given  in  the  form  of  the  ammoniated 
tincture,  very  efficient.  I  recollect  a  Manchester  surgeon,  Dr  Cromp- 
ton,  who  used  to  come  a  good  deal  to  the  Throat  Hospital  about  the 
time  it  was  founded,  telling  me  I  should  find  much  more  benefit 
by  giving  it  in  the  form  of  a  powder ;  and  I  did  so,  letting  the 
patient  take  a  pinch  of  the  resin.  This  was  rather  disagreeable, 
and  after  a  time  I  had  it  made  into  lozenges  containing  about  three 
grains  in  each.  In  this  form  it  makes  an  excellent  remedy.  Nine 
cases  out  of  ten  will  get  rapidly  well  if  one  of  these  lozenges  is  given 
every  two  hours  at  the  outset.  I  sometimes  also  apply  locally  a  little 
bismuth  and  opium,  or  an  eighth  of  a  grain  of  morphia  with  a  quarter 
of  a  grain  of  starch,  because  the  problem  is  not  only  to  cure  the 
patient,  but  to  keep  him  comfortable  till  he  is  cured.  Sometimes  the 
guaiac  causes  a  little  diarrhoea,  which  is  not  altogether  disadvan- 


1889.]  MEDICAL  NEWS.  677 

tageoiis,  but  the  morphia  is  usually  sufficient  to  check  it.  What 
I  have  said  about  guaiac  applies  to  acute  inflammations  of  any 
part  of  the  back  of  the  throat.  Dr  Home  has  said  of  guaiacum, 
"  Instar  specifici  in  hoc  morbo  operatur."  It  is  really  specific.  I 
have  used  it  for  fully  twenty  years,  and  I  assure  you  it  is  one  of 
the  best  remedies  you  could  have.  It  causes  a  slight  stinging 
sensation,  and  this  is  an  additional  reason  for  using  the  morphia. 

Occasionally  this  superficial  or  follicular  tonsillitis  if  not  checked 
passes  into  the  deep  or  parenchymatous  form,  and  the  structure  of 
the  gland  becomes  very  much  affected.  When  the  deep  inflam- 
mation occurs  you  must  bring  it  to  an  abscess  as  quickly  as 
possible,  and  open  it.  Trousseau  has  pointed  out  that  some 
inflammations  hegin  in  the  deep  part  of  the  gland,  and  these  you 
can't  check,  as  a  rule,  though  you  may  sometimes  succeed  with 
guaiac.  I  have  done  so  in  two  cases  lately.  We  are  usually,  how- 
ever, called  in  too  late.  When  you  find  you  cannot  stop  the  disease, 
give  inhalations  of  benzoin,  hop,  or  conium,  and  apply  poultices  to 
the  outside  of  the  throat.  Directly  you  can  find  fluctuation,  make  an 
opening.  As  the  tonsillitis  develops  it  prevents  the  patient  opening 
his  mouth,  and  there  is  some  difficulty  in  getting  at  the  abscess. 
This  is  the  reason  why  surgeons  sometimes  have  to  let  the  abscess 
burst,  but  this  should  be  avoided,  if  possible,  because  it  has  been 
followed  by  dangerous,  and  even  fatal,  haemorrhages.  I  generally 
use  a  curved  and  guarded  bistoury,  of  which  only  the  last  quarter 
of  an  inch  has  a  cutting  edge,  but  an  ordinary  bistoury,  the 
greater  portion  of  the  edge  of  which  is  covered  with  diachylon, 
may  also  be  used.  The  incision  is  made  with  the  cutting  edge 
directed  inwards  to  the  centre  of  the  mouth.  You  must  never  cut 
outwards,  for  there  is  then  the  danger  of  wounding  the  carotid.  I 
would  recommend  you  to  incise  in  cases  in  which  you  may  not  be 
quite  certain  of  fluctuation,  A  slight  puncture,  even  if  pus  is  not 
evacuated,  does  no  harm.  The  use  of  leeches  was  at  one  time 
common,  but  Louis  the  French  physician  proved  that  they  did  not 
cut  short  the  disease  by  more  than  one  day,  and  therefore  their 
application  was  not  desirable.  Leeches  have  the  effect  of  increasing 
the  inflammation  rather  than  otherwise  if  less  than  six  are 
applied. 

Chronic  tonsillitis,  or  hypertrophy  of  the  tonsils,  proceeds  from 
two  causes.  A  large  number  of  the  cases  are  the  result  of  a  low 
form  of  inflammation  occurring  in  childhood.  The  structure  in 
childhood  is  very  prone  to  become  inflamed.  If  the  tonsils  are 
considerably  enlarged,  it  is  important  to  remove  a  portion  of  each. 
You  should  never  speak  of  "  cutting  out  the  tonsils,"  as  this  sounds 
very  alarming  to  the  patient  and  his  friends.  Say  that  you  mean 
to  remove  only  "  the  diseased  and  enlarged  portion."  It  is  a 
consideration  when  you  should  do  this.  How  much  enlargement 
should  there  be  before  the  operation  is  performed  ?  First  of  all, 
the  question  of  size  is  entirely  relative.     In  a  large  throat  the 


678  MEDICAL   NEWS.  [jAN. 

tonsils  may  grow  to  a  considerable  size,  and  the  patient  still  do  quite 
well.  lu  a  smaller  throat  this  would  not  likely  be  the  case.  If 
the  tonsils  touch  each  other  you  can  have  no  doubt  as  to  the 
propriety  of  taking  away  a  piece.  If  adult  patients  come  to  you 
with  the  tonsils  slightly  enlarged,  it  is  an  important  question 
whether  you  should  cut  off  a  portion  or  not.  If  the  enlargement  is 
associated  with  frequent  attacks  of  acute  inflammation,  you  ought 
then  to  cut  away  a  piece.  There  is  another  condition  which 
requires  a  similar  proceeding.  When  the  follicles  of  the  tonsil  are 
much  enlarged,  you  cannot  cure  it  except  by  taking  off  a  section, 
which  may  be  not  more  than  one-eighth  of  an  inch  thick.  You 
thus  clear  away  the  walls  of  the  deep  follicles  and  get  a  flat  instead 
of  a  "  worm-eaten  "  surface.  As  to  the  method  of  operating,  many 
surgeons  do  it  with  a  bistoury,  and  Sir  William  Ferguson,  a  great 
surgeon,  for  whom  I  had  the  greatest  admiration,  used  to  perform 
it  in  this  way,  but  it  was  terrible  to  see  the  patient  struggling  with 
the  mouth  half  full  of  blood  before  the  operation  was  completed. 
Great  surgeons  will  do  all  they  can  with  a  knife  instead  of  what 
they  call  a  "machine."  I  always  perform  the  operation,  however,  with 
"a  machine,"  a  tonsillotome.  The  particular  form  I  use  is  a  modifica- 
tion of  Physick's.  The  great  advantage  of  this  is  that  its  mechanism 
is  quite  simple,  and  my  modification  enables  the  handle  to  be  fixed 
on  either  side  of  the  blade,  so  that  the  operation  may  always  be 
performed  with  the  right  hand  if  the  operator  desires.  As  a 
general  rule  lightness  of  touch  is  the  chief  desideratum  in  operating, 
but  in  tonsillotomy  it  is  the  reverse.  Heaviness  of  touch  is  the 
important  thing.  The  tonsillotome  must  be  pressed  well  over  the 
tonsil,  which  is  also  to  be  projected  into  it  by  pressure  with  the  left 
thumb  placed  under  the  angle  of  the  jaw.  I  once  had  a  colleague 
who  could  do  very  little  else,  but  he  took  off  tonsils  marvellously,  and 
as  I  watched  him  I  observed  that  it  was  this  heaviness  of  touch 
that  made  him  so  successful.  If  you  don't  attend  to  this  you  will 
not  take  off  nearly  so  much  as  you  desire.  Patients  have  come  to 
me  a  week  or  a  fortnight  after  the  performance  of  the  operation  by 
another  surgeon,  saying  that  the  tonsil  had  been  removed  but  has 
grown  again  !  This  of  course  means  that  enough  was  not  removed 
at  the  operation.  It  is  most  important  to  take  off  enough.  Haemor- 
rhage from  this  operation  is  rare,but  it  has  occurred,and  the  carotid  in 
some  instances  has  had  to  be  tied.  I  once  had  a  serious  haemorrhage 
to  deal  with  some  twenty-five  years  ago.  The  usual  styptics,  and  even 
the  cautery,  failed  to  relieve  it.  At  last  I  tried  a  remedy,  which  I 
have  used  ever  since  with  perfect  success.  A  chemist  had  informed 
me  a  short  time  before  that  a  small  quantity  of  gallic  acid  would 
prevent  tannic  acid  dissolving.  I  mixed  two  parts  of  the  tannic 
and  one  of  the  gallic  in  a  little  water,  and  gave  the  patient  two 
teaspoonf  uls,  telling  him  to  sip  them  slowly.  The  bleeding  stopped 
almost  at  once.  We  have  since  used  the  same  preparation  at  the 
Throat  Hospital,  and  always  with  perfect  success.     The  patient 


1889.]  MEDICAL  NEWS.  '  670 

must  be  told  to  swallow  tlie  liquid,  not  gargle.  Application  with 
a  brush  will  do  no  good.  He  should  swallow  the  fluid  slowly  as 
if  it  were  difficult  to  get  it  down,  and  must  on  no  account  wash 
out  his  mouth  or  gargle. 

EoYAL  College  of  Physicians. — At  the  annual  dinner  of  the 
Royal  College  of  Physicians  of  Edinburgh,  held  on  the  20th  inst., 
Sir  Andrew  Clark,  Bart.,  President  of  the  Royal  College  of  Physi- 
cians of  London,  Sir  Dyce  Duckworth,  Treasurer,  and  Dr  W.  0. 
Priestley,  one  of  the  Fellows  of  the  College,  were  present  as 
guests.  We  believe  this  is  the  first  occasion  on  which  the 
President  of  the  London  College  has  been  the  guest  of  her 
younger  sister  at  the  annual  dinner.  We  understand  Sir  Andrew 
was  very  warmly  greeted  on  rising  to  respond  to  the  toast  of  his 
College,  proposed  in  felicitous  terras  by  Dr  G.  W.  Balfour.  In  his 
reply  the  President  gracefully  acknowledged  the  compliment  that 
had  been  paid  to  the  Corporation  over  which  he  presides  and  to 
himself,  and  trusted  that  the  future  relations  of  the  two  Colleges 
would  be  of  a  cordial  character,  and  tend  to  the  elevation  of  the 
medical  profession  and  the  promotion  of  its  best  interests. 

We  have  received  from  Messrs  Danielsson  &  Co.,  London,  a 
book  containing  ten  of  their  Clinical  Charts,  to  which  they  have 
given  the  name  Perfect.  They  certainly  are  nicely  arranged,  clear 
and  distinct ;  some  of  the  spaces  are  just  small  enough  for  the  neces- 
sary entries,  but  by  abbreviations  can  be  made  to  hold  much  useful 
information. 

Messrs  Danielsson  &  Co.  have  also  an  excellent  selection  of 
outline  figures  for  recording  cases  in  a  visible  and  easily  remembered 
manner.  These  include  figures  of  brain,  thorax,  and  abdomen,  body 
with  nerve  regions,  eye,  larynx,  nose,  ear,  bones,  and  joints.  The 
use  of  these  figures  will  greatly  facilitate  rapid  and  accurate  record- 
ing of  cases,  and  they  are  cheaply  and  neatly  got  up. 

Sulphonal  (Riedel). — We  have  received  from  Burroughs, 
Wellcome,  &  Co.,  London,  a  specimen  of  this  new  hypnotic.  The 
substance  is  a  white  crystalline  powder,  tasteless  and  odourless,  and 
on  account  of  its  comparative  insolubility  is  best  given  in  powder, 
or  in  tabloids.  The  dose  of  sulphonal  is  20  to  30  grains,  but  has 
been  given  up  to  60  grains  without  any  bad  effects.  It  does  not 
act  so  speedily  as  some  otlier  hypnotics ;  but  being  tasteless  and 
odourless,  and  at  the  same  time  safe  and  effectual,  we  have  much 
pleasure  in  commending  it  to  the  favourable  consideration  of  the 
profession.     The  specimen  sent  us  is  pure,  and  can  be  trusted. 

The  Janitor  Ahead. — Philosophy  is  not  all  Nervousness. 
— Dr  Garretson  had  concluded  a  lecture  in  which  the  resurrection 
of  the  body  was  discussed  from  a  physiological  standpoint,  argument 
being  directed  to  show  that  the  astral  of  tiieosophic  language  is  quite 
as  much  a  form  of  matter  as  is  the  corpus  of  an  anatomist,  and  that 
thus  it  is  alike  philosophical  to  both  deny  and  accept  that  man  rises 


680 


PUBLIC ATIO^^S   RECEIVED. 


[JAN.  1889. 


again.  Arguments  of  the  kind  would  necessarily  soon  perplex  one 
unacquainted  with  premises  on  wliich  the  order  of  reasoning  is 
founded.  So  it  is  not  to  be  wondered  at  that  one  of  the  hearers  of 
the  lecture,  the  coloured  janitor,  who  is  more  apt  to  be  found  inside 
than  outside  the  door  on  the  occasion  of  these  discourses,  gave  up 
and  sought  relief  in  his  broom  and  dust  brush. 

"  Too  much  for  you  to-night,  was  it,  Hamilton  ?  "  asked  a  student 
passing  the  janitor  in  the  hall. 

"See  here,  boss,"  said  the  janitor,  "  dem  was  big  words,  and  no 
doubt  clar  enuf  to  the  boys,  but  what's  you  got  to  say  to  dis  dat  I 
hurd  down  to  Zion  t'other  night : 

'"  If  a  man  sits  down  on  a  pin 

Its  sartin  sure  that  he'll  rise  agin.'" 

It  is  not  reported  what  the  student  said. — Philadelphia  Medical 
Times,  Sept.  1888. 

Look  out  for  the  man  who  is  advertising  an  infallible  cure  for 
a  corn,  price  $1,  and  money  refunded  if  the  corn  does  not  disappear. 
If  you  send  him  a  dollar  you  will  receive  by  return  mail  the  follow- 
ing recipe  :  "  Cut  off  your  toe." — Philadelphia  Medical  and  Surgical 
Reporter.  

PUBLICATIONS   RECEIVED. 


Docteur    A.   Auvard, — Travaux    d'obst^t- 

rique.     Lecrosnier  et  Babe.     Paris,  1889. 
A.  H.  F.  Baebouk,  M.  a.,  M.D.,  etc.,— The 

Anatomy    of   Labour.      "W.    &    A.    K. 

Johnston,  1888. 
J.    S.   Bristowe,    M.D., — Diseases  of  the 

Nervous  System.     Smith,  Elder,  &  Co., 

Lond.,  1888. 
Thomas     Bkyant,     F.R.C.S., — Hunterian 

Lectures    on    Tension,    etc.     J.    &    A. 

Churchill,  Lond.,  1888. 
Burroughs,     Wellcome,     &     Co., — The 

A. B.C.  Medical  Diary  and  Visiting  List 

for  1889.     London,  1888. 
W.  S.  CoLMAN,  M.B., — Section  Cutting  and 

Staining.     H.  K.  Lewis,  Lond.,  1888. 
Fletcher  &  Co.'s  New  Patent  Calendar  for 

1889. 
Surg-Gen.    C.    A.    Gordon,    M.D.,— The 

Vivisection   Controversy   in   Parliament. 

Williams  &  Norgate,  Lond.,  1888. 
T.  Holmes,  M.A., —  A  Treatise  on  Surgery, 

its  Principles  and  Practice.     Smith,  Elder, 

&  Co.,  Lond.,  1888. 
T.    Mark    Hovell,    F.R.C.S.,— On    the 

Treatment  of  Cystic  Goitre.     J.  &   A. 

Churchill,  Lond.,  1888. 
Index-Catalogue    of    the    Library    of    the 

Surgeon-General's    OflBce,    U.S.    Army. 

Washington,  1888. 
Dr  KuHN, — L'enseignement  et  I'organisation 

del'artdentaireauxEtats-Unis.  Paris, 1888. 
Letts's   Medical   Diary,  1889.      Cassell  & 

Coy.,  London,  1888. 
VuLLiET   ET   LuTAUD,— Lemons  de  Gyn^- 

cologie    op^ratoire.      J.-B.    Bailliere    et 

Fils.     Paris,  1889. 
Ernest  E.  Maddox,  M.B.,  CM.,— A  Sug- 


gestion for  the  Special  Education  of  Short 

and  Weak  Sighted  Children. 
Medical     Communications    of    the    Massa- 
chusetts Medical  Society,  Vol.  xix.,  No.  2. 

Boston,  1888. 
Wm.  van   Praagh, — Papers  on  the   Pure 

Oral  Instruction  of  the  Deaf  and  Dumb. 

London, 1888. 
Sydney   Ringer,  M.D., — A   Handbook  of 

Therapeutics.     H.  K.  Lewis,  Lond.,  1888. 
R.    Lawton   Roberts,   M.D., — Illustrated 

Lectures  on  Ambulance  Work.     H.  K. 

Lewis,  Lond.,  1888. 
Dr  B.  S.  ScHULTZE, — Pathology  and  Treat- 
ment of   Displacements  of  the    Uterus. 

Smith,  Elder,  &  Co.,  Lond,  1888. 
Selected    Monographs.       New     Sydenham 

Society,  Lond.,  1888. 
W.    R.    H.    Stewart,    F.R.C.S.,    etc.,— 

Epitome  of  Diseases  and  Injuries  of  the 

Ear.     H.  K.  Lewis,  Lond.,  1888. 
Lawson    Tait,    F.R.C.S., — Lectures    on 

Ectopic  Pregnancy  and  Pelvic  Haemato- 

cele.     Birmingham,  1888. 
The  Medical  and  Surgical  History  of  the 

War  of  the  Rebellion,  Part  III.,  Vol.  1. 

Washington,  1888. 
Sir    Henry    Thompson, — Diseases  of  the 

Urinary    Organs.      J.    &    A.    Churchill, 

Lond.,  1888. 
Transactions  of  the  Obstetrical  Society  of 

London,  Vol.  xxx..  Part  2.  London,  1888. 
B.  0.  A.  WiNDLE,  M.A.,  M.D.,— A  Hand- 
book of  Surface  Anatomy  and  Landmarks. 

H.  K.  Lewis,  Lond.,  1888. 
R.  N.  WoLFENDEN,  M.D.,  and  S.  Martin, 

M.D., — Studies  in  Pathological  Anatomy, 

Fasc.  2.    J.  &  A.  Churchill,  Lond.,  1888. 


patt  dTttst. 


OKIGINAL    COMMUNICATIONS. 

I— AN   EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 

STOKES  EESPIRATION. 

By  G.  A.  Gibson,  M.D. 

{Continued  from  page  596.) 

Haehndel^  enters  very  fully  into  the  whole  matter  in  his 
inaugural  dissertation.  After  some  historical  and  critical  observa- 
tions he  mentions  that  he  had  frequently  noticed  the  appearance 
of  groups  of  shallow  or  superficial  respirations  without  any  pause. 
Such  a  phenomenon  he  considers  to  be  a  transition  towards  the 
more  fully  developed  form,  and  he  explains  it  in  a  manner  similar 
to  Traube's  theory.  He  thereafter  narrates  seven  cases  of  Cheyne- 
Stokes  breathing  which  he  had  personally  observed : — Mitral 
incompetence,  with  embolism  of  the  right  Sylvian  artery  ;  chronic 
endocarditis,  with  mitral  and  aortic  lesions  and  thrombosis  of  the 
left  internal  carotid  artery ;  aortic  incompetence,  with  fatty 
degeneration  of  the  muscular  structure  and  hypertrophy  and 
dilatation  of  the  heart ;  sclerosis  of  the  coronary  arteries,  with 
cardiac  hypertrophy,  and  stenosis  of  the  inferior  vena  cava  from 
hepatic  fibro-sarcoma ;  mitral  stenosis,  with  atheroma  of  the 
arteries  of  the  base  of  the  brain,  and  softening  of  the  left  optic 
thalamus ;  chronic  renal  disease  with  uraemia ;  and,  lastly,  chronic 
renal  disease  with  mitral  incompetence.  In  his  remarks  on  these 
cases  he  calls  attention  in  one  instance  to  the  persistence  of 
consciousness  throughout  all  the  phases  of  the  breathing,  and  in 
another  to  the  pupillary  changes  which  were  present,  but  which 
did  not  in  all  respects  coincide  with  the  appearances  described  by 
Leube. 

In  this  thesis  the  author  refers  to  a  case  which  he  attributes  to 
Erb,  in  which  cerebro-spinal  meningitis  was  accompanied  by 
Cheyne- Stokes  respiration,  the  cause  of  which  had  been  supposed 
to  be  the  presence  of  purulent  exudation  surrounding  the  medulla 
oblongata.  No  trace  of  tliis  observation  is  to  be  found  in  litera- 
ture elsewhere,  and  Professor  Erb  informs  me  that  he  has  never 
written  or  spoken  on  the  subject. 

Lutz^  describes  a  case  of  scarlatina  followed  by  suppuration  of 

^   Ueher  das  Cheyne- Stakes' sche  Respirations- Phanomen.     Breslau,  1870. 
'  Deutsches  Archiv  filr  klinische  Medicin,  viii.  Band,  S.  123,  1870. 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    VIII.  4R 


682  DR   G.    A.    GIBSON    ON    THE  [FEB. 

the  ear  and  cerebral  symptoms,  during  the  presence  of  which  the 
respiration  assumed  this  pecuUar  rhythm. 

Bjornstrom^  says  that  the  phenomenon  is  probably  not  so  rare 
as  might  be  imagined  from  the  paucity  of  literature  concerning  it, 
and  describes  three  cases  which  he  had  seen.  The  first,  a  child 
three  months  old,  was  ill  with  capillary  bronchitis,  and  during  the 
last  four  days  of  life  manifested  this  phenomenon.  The  second 
patient,  aged  seventeen  years,  suffered  from  tubercular  meningitis, 
but  here  the  symptom  was  not  typical,  and  was  accompanied  by 
divergent  strabismus.  The  last  case  was  that  of  a  patient  of  the 
age  of  seventy  years  affected  by  fatty  degeneration  of  the  heart. 
The  author  regards  Cheyne-Stokes  respiration  as  lethal.  He  does 
not  approve  of  Traube's  theory,  but  declines  to  formulate  another. 
He  further  objects  to  the  name  by  which  the  symptom  is  known. 

In  the  discussion  which  followed  the  reading  of  this  paper,  Glas 
mentioned  that  he  had  seen  stoppages  of  breathing  in  a  case  under 
his  care,  and  a  description  of  the  case  is  given  further  on^  in  the 
same  publication.  The  patient  in  this  case,  who  was  a  man  aged 
70,  suffering  from  traumatic  gangrene,  had  pauses  in  the  respira- 
tion, without  any  change  in  the  state  of  the  circulation. 

Heidenhain,^  in  a  most  interesting  paper  on  Cyon's  theory  of 
the  central  innervation  of  the  vaso-niotor  nerves,  points  out  that 
he  has  observed  the  Cheyne-Stokes  phenomenon  in  chloralized 
animals,  and  he  gives  a  tracing  showing  the  rhythm  of  the 
respiration,  which  perfectly  corresponds  with  that  which  we 
obtain  in  cases  of  disease  in  man.  He  draws  attention  to  the  fact 
,hat  during  the  respiratory  period  the  blood-pressure  rose  slightly. 
Bruckner*  makes  a  brief  reference  in  1871  to  the  fact  that  his 
deceased  father  had,  twenty-two  years  before  the  date  of  his 
communication,  called  his  attention  to  the  phenomenon  of  Cheyne- 
Stokes  respiration,  and  given  it  the  name  of  "pendulum-like 
breathing,"  because  the  alternation  of  the  breathing  and  the 
pauses  is  as  regular  as  the  swinging  of  a  pendulum.  The  author 
mentions  that  he  has  frequently  watched  the  symptom,  particu- 
larly in  cases  of  tubercular  meningitis. 

Eehn^  describes  two  cases  of  pulmonary  disease  in  children, 
which  presented  this  symptom.  One  was  a  child  of  one  year  of 
age,  suffering  from  pneumonia;  the  other  an  infant  six  weeks  old, 
labouring  under  bronchitis.  For  the  explanation  of  the  pheno- 
menon he  accepts  the  theory  that  there  is  a  lessened  access  of 
\rterialized  blood. 

1  Upsala  Lakareforenings  Forhandlingar,  vi.  Band,  S.  307,  1870-1871. 

2  Ibid.,  S.  315. 

3  Archiv  fur  die  gesammte  Physiologie  des  Menschen  und  der  Thiere,  iv. 
/ahrgang,  S.  554,  1871. 

*  Archiv  fiir  pathologische  Anatomie  und  Physiologie  und  fiir  klinische 
Medicin,  lii.  Band,  S.  155,  1871. 

*  Jahrhuch  fiir  Kinderheilkunde  und  physische  Erziehung,  neue  Folge,  iv. 
Jalirgang,  S.  432,  1871. 


1889.]  J'HEKOMENA    IN    CHEYNE-STOKES   RESPIEATION.  683 

MerkeP  records  a  case  in  which  the  patient,  who  suffered  from 
renal  disease  with  cardiac  dilatation  and  pulmonary  emphysema, 
was  attacked  by  apoplexy  a  year  before  his  death.  During  the 
cerebral  symptoms,  Ciieyne-Stokes  respiration  made  its  appearance, 
and  during  the  pause,  narrowing  of  the  pupils  and  absence  of 
reaction  to  light  were  observed,  along  with  dulness  of  the  mind. 
The  author  mentions  that  if  a  question  was  asked  at  the  end  of  a 
period  of  breathing,  it  was  answered  at  the  beginning  of  the  next 
period  after  the  termination  of  tlie  intervening  respiratory  pause. 
The  patient  recovered  from  this  seizure,  and  on  his  death,  about  a 
year  later,  it  was  found  that  in  addition  to  granular  kidneys, 
emphysematous  lungs,  and  a  dilated  and  hypertrophied  heart,  with 
cyanotic  atrophy  of  the  liver  and  spleen,  there  was  destructive 
disease  in  the  corpus  striatum,  optic  thalamus,  and  pons.  In 
another  case  narrated  subsequently,^  the  same  author  found  this 
type  of  respiration  in  association  with  endocarditis  and  embolism  of 
one  of  the  posterior  branches  of  the  right  artery  of  the  Sylvian  fossa. 
He  found  that  even  with  total  absence  of  reaction  to  light  the 
pupils  became  distinctly  smaller  at  the  beginning  of  the  pause. 

Schepelern^  describes  several  cases  in  which  he  met  with  this 
type  of  breathing,  and  adds  to  the  rapidly  advancing  store  of  know- 
ledge in  regard  to  the  symptoms  associated  with  it.  The  first 
patient  was  a  man,  aged  54.  In  this  case  the  phenomenon 
appeared  after  a  period  of  breathlessness  and  palpitation.  The 
patient  felt  most  comfortable  at  tlie  beginning  of  the  apnoea,  and 
became  unconscious  towards  the  end  of  it,  but  could  be  awakened 
out  of  this  state,  and  was  able  to  talk  during  the  pause.  No  con- 
vulsive or  involuntary  movements  were  present  in  the  muscles  or 
eyes.  Ophthalmoscopic  examination  of  the  eyes  showed  nothing 
beyond  a  slight  patch  of  haemorrhage  near  one  papilla,  and  fulness 
of  the  veins.  There  was  no  variation  in  the  size  of  the  vessels  of 
the  fundus  during  the  changing  phases  of  respiration.  The 
patient  could  be  caused  to  breathe  during  the  pause  of  respiration 
by  constantly  ordering  him  to  do  so,  and  this  lessened  the  subsequent 
period  of  dyspnoea.  Electric  stimulation  of  the  phrenic  nerves 
during  the  pause  produced  no  result.  The  relative  duration  of 
the  apnoea  and  dyspnoea  was  not  affected  by  sleep.  The  pulse 
remained  small  throughout  the  different  phases  of  respiration, 
without  apparent  change  in  strength  or  tension,  but  the  number 
of  pulsations  was  less  during  the  period  of  breathing,  probably 
from  intermission  which  was  present.  On  section  the  heart  was 
fatty,  the  aorta  and  arteries,  especially  the  vertebral  and  basilar, 
atheromatous,  the  liver  was  fatty,  and  the  kidneys  cyanotic. 

The  second  case  was  that  of  a  man,  75  years  old,  suffering  from 
bronchitis   with  ascites   and   albuminuria.       The    Cheyne-Stokes 

^  Deutsches  Archivfiir  klinische  Medicin,  viii.  Band,  S.  424,  1871. 

2  Ibid,  X.  Band,  S.  201,  1872. 

3  Hospitals- Tidende,  XV.  Aargang,  S.  77,  81,  og  85,  1872. 


684  Bll   G.   A.   GIBSON   ON   THE  [FEB. 

respiration  was  well  marked,  but  was  not  attended  by  muscular 
twitchings  or  pupillary  variations.  The  patient  could  be  made  to 
speak  during  the  pause,  but  could  not  be  caused  to  breathe  during 
that  phase,  and  electric  stimulation  of  the  phrenic  nerves  pro- 
duced no  result.  There  was  no  alteration  in  the  rate  or  strength 
of  the  pulse  during  the  changing  respiratory  phases.  There  was 
no  examination  after  death. 

The  third  case  was  that  of  a  man,  aged  69,  of  gouty  habit, 
suffering  from  aortic  disease  and  cardiac  hypertrophy  with  albu- 
minuria.    There  was  no  autopsy  in  tliis  case. 

The  fourth  patient,  a  woman  about  60  years  old,  was  affected 
by  mitral  disease.  On  section  there  was  stenosis  and  incompetence 
of  the  mitral  orifice  and  valve,  with  hypertrophy  of  the  left  and 
dilatation  of  the  right  ventricle,  and  a  fatty  heart.  There  was 
degeneration  of  the  cerebral  arteries  and  old  tubercular  disease  of 
the  apex  of  the  right  lung. 

Schepelern  supports  the  theory  of  Traube,  and  believes  the  dulness 
of  the  mental  faculties  to  be  caused  by  the  presence  of  an  excess  of 
carbonic  acid  in  the  blood.  He  does  not  approve  of  the  view  ad- 
vanced by  Traube,  that  the  mental  obscurity  is  the  result  of  cerebral 
antemia.  The  dyspnoea  he  attributes  to  the  action  of  the  carbonic 
acid  on  the  sensory  nerves,  and  he  compares  this  to  the  forced 
breathing  seen  after  section  of  the  vagi ,  when  the  sen sory  nerves  alone 
act  as  the  respiratory  stimulants.  He  states  that  he  has  never  seen 
any  deepening  of  the  symptoms  after  the  use  of  morphine  or  chloral. 

In  conclusion,  he  describes  another  case,  that  of  a  man,  aged  39, 
who,  after  paralysis  of  the  left  side  with  loss  of  speech,  suddenly 
became  ursemic,  with  delirium  and  sopor,  and  paralyzed  on  the 
other  side.  During  the  unconsciousness  which  deepened  into 
coma,  the  characteristic  Cheyne-Stokes  respiration  appeared,  and 
with  it  changes  in  the  pupils  were  observed.  They  became  larger 
during  the  period  of  respiration,  even  after  the  application  of 
atropine,  and  the  author  regards  the  dilatation,  therefore,  as  purely 
due  to  the  influence  of  the  sympathetic  nerve.  Nothing  note- 
worthy could  be  seen  on  ophthalmoscopic  examination  of  the  eyes. 
On  section,  the  kidneys  were  found  to  be  granular,  the  heart 
degenerated,  the  arteries  atheromatous ;  there  was  also  thrombosis 
of  the  cerebral  vessels  and  patches  of  softening  of  the  brain,  but 
the  pons  and  medulla  were  healthy. 

Roth  places  two  cases  on  record,^  one,  that  of  a  child,  aged  7 
months,  suffering  from  meningitis,  the  other,  that  of  a  girl,  with 
urtemia  and  eclampsia,  in  which  the  typical  respiration  was  present. 

Korber^  describes  the  symptom  as  it  occurred  in  a  boy  of  9 
months,  suffering  from  tubercular  meningitis,  and  notes  that  during 
the  pause  a  certain  stiffness  of  the  paralyzed  limbs  came  on,  while 
during  the  period  of  breathing  they  were  quite  flexible. 

^  Deutsches  Archiv  fiir  klinische  Medicin,  i.  Band,  S.  310,  1872. 
3  Ibid.,  X.  Band,  S,  600,  1872. 


1889.]  PHENOMENA    IN    CHEYNE-STOKES    KESPIKATION.  685 

A  paper  by  Filelme^  deserves  mention  here,  as  in  it  he  points 
out  that  after  section  of  the  vagi  it  is  possible  to  cause  apnoea,  and 
carefully  discriminates  between  true  apnaa,  or  arrest  of  respiration 
from  excessive  oxidation  of  the  blood,  and  arrest  of  respiration 
caused  by  other  conditions. 

Laycock^  enters  very  fully  into  the  phenomenon  of  ''  Brief 
Eecurrent  Apnoea,"  as  he  terms  the  Cheyne-Stokes  respiration,  in 
a  very  interesting  lecture,  but  he  cannot  be  regarded  as  adding 
anything  of  importance  to  the  pathology  of  the  condition.  It  is  a 
singular,  nay,  even  startling  fact,  that  he  makes  no  mention  of 
Traube  in  his  remarks,  although  in  them  he  does  full  justice  to 
most  of  those  who  had  written  on  the  subject  in  the  vernacular. 
He  refers  to  the  case  which  has  been  already  mentioned  in 
connexion  with  his  name. 

The  same  writer  immediately  afterwards  contributed  another 
paper  on  this  subject  to  medical  literature^  which  is  substantially 
the  same  as  that  to  which  reference  has  just  been  made. 

Two  or  three  months  after  the  publication  of  Laycock's  remarks, 
Bernheim,^  who  had  the  good  fortune  to  be  present  at  the  historic 
clinique  when  Traube  expounded  his  theory,  gave  an  excellent 
review  of  much  of  the  work  that  had  been  done  on  the  Continent, 
along  with  an  account  of  four  cases  which  he  had  himself  observed. 
These  four  cases  were  respectively — heart  disease  with  emphysema; 
chronic  alcoholism  with  nephritis ;  pulmonary  tuberculosis  and 
dilated  heart ;  and  the  result  of  a  fall  from  a  great  height.  He 
points  out  that  Cheyne-Stokes  respiration  is  only  the  highest 
expression  of  a  series  of  similar  phenomena,  in  the  less  marked  of 
which  there  is  no  pause,  but  alternations  of  deep  and  shallow 
breathing,  and  he  gives  the  result  of  a  careful  study  of  the  eye 
and  pulse  during  the  phases  of  the  respiration.  The  pulse  he 
describes  as  being  sometimes  altered,  and  at  other  times  unchanged 
during  tlie  alternations  of  dyspnoea  and  apnoea.  Like  Leube  he 
found  that  electricity  would  stop  the  pauses  for  a  time. 

Monti,  in  an  exhaustive  research  into  the  physical  examination 
of  the  thoracic  viscera  of  cliildren,^  gives  it  as  his  opinion  that 
Cheyne-Stokes  respiration  in  children  only  occurs  during  the  last 
stages  of  life,  and  that  it  is  always  to  be  attributed  to  disturbances 
of  the  centres  of  the  nervous  system. 

Eohrer^  describes  a  case  of  tul)ercular  meningitis  in  which 
Cheyne-Stokes  breathing  was  present,  and  explains  it  by  means  of 
Traube's  theory. 

1  Archiv  fiir  Anatomie,  Physiologic,  und  wissenschaftlichen  Medicin,  Jahrgang 
1873,  S.  361. 

^  The  Medical  Times  and  Gazette,  vol.  i.  for  1873,  p.  433. 

^  The  Dublin  Journal  of  Medical  Science,  vol.  Ivi   p.  1,  1873. 

*  Gazette  Hebdomadaire  de  Medecine  et  de  Chirurgie,  Deuxieme  S^rie,  tome  x. 
p.  444  et  p.  492,  187.^. 

^  Oesterreichisches  Jahrhuch  fiir  Piidiatrie,  neue  Folge,  ii.  Band,  S.  173,  1873. 

^  Correspondenz-Blatt  fiir  schweizer  Aerzte,  iii.  Jahrgang,  S.  225,  1873 


68G  Dll   G.    A.   GIBSON   ON   THE  [FEB. 

Clivostek^  records  a  case  of  mitral  incompetence  in  which  the 
phenomena  of  Clieyne-Stokes  respiration  were  fully  developed, 
and  goes  on  to  discuss  and  criticise  the  various  symptoms  present, 
as  well  as  those  mentioned  hy  other  writers,  after  which  he 
states  the  theory  of  Traube.  Tiiis  paper  is  of  extreme  interest,  as 
it  gives  one  of  the  best  critical  studies  of  the  various  appearances 
which  attend  the  type  of  respiration. 

So  far  no  one  had  ventured  to  oppose  the  theory  of  Traube,  but 
in  the  following  year  it  entered  upon  a  period  of  storm  and  stress 
which  has  continued  ever  since.  In  that  year  Filehne^  subjected 
the  theory  to  a  searching  criticism,  and  insisted  on  such  modifica- 
tions of  it  that  we  are  quite  justified  in  saying  that  he  propounded 
a  rival  theory.  He  states  in  his  contribution  that  he  has  produced 
Cheyne-Stokes  respiration  by  the  administr.ition  of  ether  and 
chloroform  to  animals  poisoned  by  means  of  large  doses  of 
morphine,  and  grants  that,  for  the  production  of  this  symptom, 
there  must  be  lowered  irritability  of  the  respiratory  centre;  he 
asserts  that  this,  however,  is  not  enough,  and  that  the  irritability 
of  the  respiratory  centre  must  be  less  than  that  of  the  vaso-motor 
centre,  which  is  the  converse,  according  to  him,  of  the  normal 
relationship  existing  between  these  centres  and  the  condition  of 
the  blood.  He  states,  further,  that  the  phenomenon  may  occur, 
although  in  a  modified  form,  after  both  vagi  have  been  cut ;  and 
h^,  therefore,  is  of  opinion  that  it  is  not  dependent  on  the  integrity 
ot\these  nerves,  whence  he  concludes  that  a  new  theory  is  abso- 
lutely necessary.  He  points  out  that  the  centres  remain  at  rest 
so,  long  as  they  are  supplied  with  a  sufficient  amount  of  blood 
containing  an  adequate  quantity  of  oxygen ;  that  they  are  excited 
whenever  the  blood-supply  is  insufficiently  arterialized,  or  when, 
although  sufficiently  arterialized,  the  supply  is  deficient  in  quantity  ; 
and  that  the  excitement  is  greatest  when  the  blood-supply  is  too 
small  and  at  the  same  time  inadequately  arterialized.  He  asserts 
that  in  health  venous  blood  excites, — 1st,  the  respiratory,  2nd, 
the  vaso-motor,  and  3rd,  the  convulsive  centres.  Picturing  a  case 
in  which  the  phenomenon  is  present,  he  says  that  during  the  pause 
the  blood  gradually  becomes  more  venous  and  develops  the 
stimulus  for  the  centres,  but  that,  from  the  lessened  irritability 
of  the  respiratory  centre,  no  respiration  is  caused,  and  the  pause 
therefore  continues  until  the  point  is  reached  when  the  vaso-motor 
centre  is  brought  into  action.  This  produces  a  diminution  of  the 
blood-supply,  which  causes  the  respiratory  centre  to  act  and 
originate  the  superficial  breathing  which  is  first  observed.  It  is 
some  time,  however,  before  the  blood  arterialized  by  these  respira- 
tions can  reach  the  vaso-motor  centre,  and  the  time  is  lengthened 
by  the  contraction  of  the  arterioles  caused  by  its  activity ;  it  takes 
time,  moreover,  before  the  vaso-motor  apparatus  can  induce  con- 

1  Wiener  medizinische  Wochenschrift,  xxiii.  Jahrgang,  S.  899  und  922,  1873. 

2  Berliner  klinische  Wochenschrift,  xi.  Jahrgang,  S.  152  und  165,  1874. 


1889.J  PHENOMENA   IN    CHEYNE-STOKES   RESPIRATION.  687 

traction  of  the  arterioles,  and  time  also  before  the  contraction  can 
pass  away ;  there  is  therefore  a  lengthening  of  the  pause  and 
deepening  of  the  dyspnoea.  He  states  that  when  Cheyne-Stokes 
respiration  is  produced  in  animals  by  the  administration  of  large 
doses  of  morphine,  followed  by  the  inhalation  of  ether  or  chloroform, 
there  is  always  a  gradual  diminution  of  the  pulse-rate  during  the 
pause,  which  sometimes  goes  the  length  of  complete  cessation  of 
the  pulsation  ;  while  during  the  period  of  respiration  there  is  a 
gradual  acceleration  until  the  normal  rate  is  regained  towards  the 
end  of  this  phase.  He  states  further,  that  in  the  animals  thus 
experimented  on,  the  blood-pressure  rises  during  the  pause  and 
falls  during  the  period  of  breathing.  He  mentions  the  case  of  a 
man  who  died  after  a  lethal  dose  of  morphine  and  chloroform, 
showing  during  the  narcosis  Cheyne-Stokes  respiration  exactly  in 
the  same  form  as  seen  in  his  experimental  investigations.  The 
pulse  underwent  the  same  changes  as  he  observed  in  the  animals 
on  which  he  performed  his  experiments.  Finally,  in  his  criticism 
of  Traube's  theory  he  asserts  that  the  periodicity  of  the  Cheyne- 
Stokes  respiration  could  only  depend  upon  a  periodicity  of  action 
of  the  respiratory  centre  which  has  not  been  proved. 

In  the  discussion  which  followed  Filehne's  paper,  Ewald^  stated 
that  he  had  examined  during  breathing  as  well  as  pause  the  retina 
of  a  patient  in  whom  the  pulse  underwent  alterations,  but  had 
been  unable  to  detect  any  distinct  changes. 

Traube^  promptly  came  forward  in  defence  of  his  theory.  In 
his  reply  he  points  out  that  Filehne  had  arbitrarily  postulated 
that  the  respiratory  centre  must  have  less  irritability  than  the 
vaso-motor  centre,  and  that  this  postulate  had  been  based  on  the 
gratuitous  assumptions, — 1,  that  the  vaso-motor  system  is  always 
implicated ;  2,  that  the  vaso-motor  is  normally  less  irritable  than 
.the  respiratory  centre ;  and  3,  that  two  centres  are  not  proportion- 
ately affected  by  a  proportional  diminution  of  oxygenated  blood. 
He  states,  with  regard  to  the  first  of  these  points,  that  there  is 
very  often  no  change  in  the  arterial  tension  during  the  different 
phases  of  the  phenomenon ;  with  reference  to  the  second,  that  the 
vaso-motor  is  more  irritable  than  the  regulator,  while  this  is  more 
sensitive  than  the  respiratory  centre  ;  and  he  curtly  dismisses  the 
third  as  absurd.  He  holds  that  a  rhythmic  periodicity  of  the 
respiratory  centre  has  been  proved  as  distinctly  as  in  the  case  of 
the  vaso-motor  and  inhibitory  centres — all  being  dependent  on  the 
changing  quantity  of  carbonic  acid  and  consequent  stinmlation  and 
exhaustion  of  the  centres.  Traube  concludes  his  reply  with  a 
restatement  of  his  theory,  pointing  out  that  all  cases  in  which  the 
phenomenon  appears  have  lessened  irritability  of  the  respiratory 
centre,  and  therefore  require  more  carbonic  acid  to  excite  respira- 
tion, which  of  necessity  requires  a  longer  interval  of  time.     At 

^  Berliner  klinische  Wochenschrift,  xi.  Jahrgang,  S.  169,  1874. 
2  Ibid.,  S.  185  und  209,  1874. 


G88  DU   G.    A.    GIBSON    ON    THE  [fER. 

first  the  necessary  carbonic  acid  will  be  in  the  lungs,  and  the  peri- 
l^lienil  endings  of  the  vagi  are  tlie  earliest  to  be  stimulated.  Tiiis, 
however,  causes  no  dyspucea,  only  the  superHcial  breathing,  but 
when  the  carbonic  acid  has  accumulated  in  sufficient  quantity  to 
excite  the  sensory  nerves  dyspnoea  is  produced.  In  consequence, 
however,  of  the  diminution  of  the  carbonic  acid,  as  well  as  on 
account  of  the  exhaustion  of  the  respiratory  centre  by  the  powerful 
irritation,  the  breathing  loses  its  dyspnoeic  character,  and  as  the 
exhaustion  of  the  centre  gains  ground  more  rapidly  than  the 
accumulation  anew  of  carbonic  acid,  the  breathing  becomes  more 
and  more  superficial,  ending  in  another  pause.  It  is  to  be  observed 
that  in  this  second  enunciation  of  his  tlieory  Traube  introduces 
the  factor  of  exhaustion. 

Filehne*  again  returned  to  the  charge.  In  his  answer  to  Traube 
he  reasserts  the  action  of  the  vaso-motor  system  as  the  basis  of  the 
Cheyne-Stokes  phenomenon.  He  refers  to  his  own  experiments 
and  to  the  observations  of  Heidenhain  on  chloralized  dogs  in 
support  of  his  position,  as  well  as  the  rise  of  arterial  tension  in 
patients  before  the  commencement  of  respiration,  and  the  dilatation 
of  the  pupil  at  the  same  stage,  which,  if  not  due  to  a  dilator 
pupillse  muscle,  must  be  caused  by  contraction  of  the  vessels.  In 
this  connexion  he  asserts  that  the  finger  cannot  be  accepted  as 
any  criterion  of  the  tension  of  the  radial  artery.  He  brings 
forward  the  state  of  the  fontanelles  in  little  children  presenting 
this  plienomenon  as  a  proof  of  his  theory,  and  states  that  he 
observed  in  one  case  a  depression  of  the  fontanelles  before  the 
commencement  and  during  the  early  part  of  the  period  of  breathing. 
The  normal  condition  was  regained  towards  the  end  of  the 
respiratory  period.  This  he  holds  to  prove  contraction  of  the 
vessels.  In  the  case  of  a  child  when  the  Cheyne-Stokes  respira- 
tion disappeared  it  could  be  brought  back  by  the  application  of 
pressure  upon  the  fontanelles.  He  mentions  the  case  of  a  woman 
suffering  from  degeneration  of  the  cord  and  medulla,  in  whom 
Cheyne-Stokes  respiration  was  present ;  when  nitrite  of  amyl  was 
administered  the  phenomenon  disappeared  and  remained  absent  as 
long  as  the  inhalation  was  continued.  He  gives  details  of  experi- 
ments in  which  the  peculiar  type  of  respiration  was  produced  by 
interference  with  the  supply  of  blood  to  the  brain  by  alternate 
compression  and  relaxation  of  the  carotids  and  vertebral  arteries 
in  the  rabbit.  He  further  mentions  a  rise  of  tension  found  in 
some  persons  before  the  act  of  inspiration  which  is  not  normal, 
and  which  he  holds  to  prove  that  in  them  the  vaso-motor  is 
affected  before  the  respiratory  centre.  The  paper  ends  with  a 
criticism  of  Traube's  reply  to  his  previous  communication. 

Heitler^  begins  an  interesting  study  of  this  symptom,  by  pointing 
out  that  although  far  more  common  in  unconsciousness  it  is  not 

1  Berliner  klinische  Wochenschrift,  xi.  Jahrgang,  S.  404  und  435,  1874. 

2  Wiener  medizinische  Pretse,  xv.  Jahrgang,  S.  649  und  672,  1874. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   EESPIEATION.  689 

invariably  associated  with  that  condition.  He  states  that  he  has 
seen  Cheyne-Stokes  respiration  in  chronic  hydrocephalus ;  in 
typhoid  fever ;  in  pneumonia ;  in  tubercular  meningitis ;  and  in 
tubercular  laryngeal  perichondritis  where  tracheotomy  had  to  be 
resorted  to.  He  calls  attention  to  the  fact,  that  although  the  fully 
developed  symptom  cannot  be  regarded  as  common,  less  pro- 
nounced forms  of  the  same  phenomenon  are  yet  of  frequent 
occurrence,  and  constitute  a  gradation  between  slight  irregularity 
of  the  breathing  and  the  Cheyne-Stokes  respiration.  A  critical 
description  of  the  breathing  follows,  in  which  the  author  mentions 
that  he  has  not  observed  any  very  characteristic  changes  in  the 
condition  of  the  circulation  except  in  the  most  pronounced  cases 
where  the  pulse  underwent  slight  modifications.  He  then  states 
the  later  theory  of  Traube,  and  goes  on  to  describe  two  of  his  cases, 
one  being  chronic  hydrocephalus  and  the  other  tuberculosis. 

In  the  course  of  a  case  of  insolation  from  which  perfect  recovery 
took  place,  Zimmerhans^  observed  the  phenomenon  of  Cheyne- 
Stokes  breathing,  for  the  explanation  of  which  he  accepts  some 
medullary  change  as  the  cause. 

Hoepffner^  describes  a  case  of  cerebral  disease  in  which  Cheyne- 
Stokes  respiration  was  one  of  the  prominent  symptoms.  In 
this  case  electricity  was  applied  along  the  course  of  the  pneumo- 
gastric  nerve  without  effecting  any  change  in  the  respiratory 
symptoms. 

An  excellent  summary  of  the  discussion  between  Traube  and 
Filehne  appeared  at  this  time  from  the  pen  of  Ricklin^  in  which, 
however,  no  new  facts  or  views  were  brought  forward. 

In  some  observations  on  intermittent  respiration  in  the  insane, 
Zenker*  narrates  six  cases  in  which  he  states  that  Cheyne-Stokes 
breathing  was  developed.  Some  of  these  cases  do  not  give  in 
their  intermitting  respiration  the  true  features  of  Cheyne-Stokes 
breathing,  but  in  three  of  them  it  appears  to  have  been  undoubtedly 
present.  In  none  of  the  cases  described  was  there  any  periodic 
variation  in  the  state  of  the  pupil  or  pulse.  It  is  interesting  to 
notice  that  in  two  of  these  cases  the  periodic  breathing  was 
associated  with  epilepsy,  and  Zenker  points  out  in  this  connexion 
that  it  is  due  to  the  proximity  of  the  respiratory  and  convulsive 
centres.  In  regard  to  the  causation  of  the  phenomenon,  Zenker 
says  that  there  can  be  no  doubt  it  is  due  to  a  disturbance  of  the 
respiratory  centre,  for  the  explanation  of  which  it  is  necessary  to 
clear  up  several  physiological  and  pathological  questions. 

Benson,  whose  previous  observations  on  this  subject  have  been 
already  referred  to,  brought  the  matter  before  the  Medical  Society 

1  Wiener  medizinische  Presse,  xv.  Jahrgang,  S.  771,  1874. 

2  Gazette  meUicale  de  Strasbourg,  xxxiii"  Annee,  p.  lOl,  1874. 

^Gazette  mMicale  de  Paris,  £lv*  Annee,  4*  Serie,  tome  iii.  pp.  519,  530, 
et  565,  1874. 

'^  Allgemeine  Zeitschrift  fiir  Psychiatrie  und  psychischgerichtliche  Medicin, 
XXX.  Band,  S.  419,  1874. 

EDINBURGH   MED.    JOUEN.,   VOL.    XXXIV. — NO.   VIII.  4  S 


690  DU   G.   A.   GIBSON   ON   THE  [FEB. 

of  the  Irish  College  of  Physicians/  and  in  briefly  detailing  the 
facts  of  a  recent  case,  took  occasion  to  mention  some  of  the 
theories  which  had  been  propounded,  and  to  compare  Traube's 
explanation  with  his  own.  He  points  out  that  in  the  case  which  he 
recorded,  in  which  there  was  hemiplegia  followed  by  cardiac  failure, 
the  peculiar  type  of  respiration  did  not  appear  until  the  cardiac 
symptoms  had  added  themselves  to  the  cerebral,  adding  that  in 
the  previous  case  which  he  narrated  the  phenomenon  only  appeared 
after  the  cerebral  symptoms  had  added  themselves  to  the  cardiac. 

Following  Benson's  remarks,  Henry  Kennedy  mentioned^  that 
he  had  been  led  to  the  conclusion  that  the  symptom  was  more  or 
less  connected  with  the  nervous  system  generally  rather  than  with 
any  particular  organ  connected  with  the  chest,  which  view  was 
confirmed  by  some  common  phenomena,  such  as  the  alteration  of 
breathing  in  sleep,  showing  that  the  breathing  may  vary  in  health  ; 
the  cerebral  breathing  of  Graves  in  fever ;  or  the  changes 
of  respiration  in  hydrocephalus.  He  thought  there  was  evidence 
enough  to  prove  that  a  temporarily  modified  state  of  the  nervous 
system  might  be  capable  of  altering  and  modifying  the  breathing. 
He  mentioned  an  interesting  fact  that,  in  patients  showing  this 
type  of  respiration,  the  ascending  and  descending  character  dis- 
appeared when  they  were  placed  on  their  sides. 

A  case  of  diphtheria  in  a  boy  2^  years  old  afforded  v,  Hiitten- 
brenner^  the  opportunity  of  studying  Cheyne-Stokes  breathing, 
which  he  attributes  in  this  instance  primarily  to  weakness  of  the 
heart  from  the  diphtheritic  poison.  He  refers  to  the  Traube- 
Filehne  controversy,  but  refrains  from  criticism. 

Bull*  has  placed  three  cases  on  record  in  which  the  peculiar 
breathing  in  question  was  noticed.  The  patients  in  whom  it  ap- 
peared suffered  from  chronic  renal  disease,  with  sclerosed  arteries, 
hypertrophied  heart,  and  cerebral  hemorrhage ;  granular  kidney, 
arterial  atheroma,  cardiac  hypertrophy,  and  pericarditis ;  and  duo- 
denal cancer,  in  which,  after  the  use  of  morphine  for  the  agony 
caused  by  the  disease,  Cheyne-Stokes  breathing  appeared.  In  a 
letter  which  the  author  has  kindly  addressed  to  me,  he  states  that 
he  is  not  satisfied  with  any  of  the  present  theories. 

Hayden  fully  discusses  the  phenomenon  in  his  work,^  and  gives 
the  following  explanation  of  it : — "  I  have  already  stated,"  he  says, 
"  that  the  only  lesion  of  structure  with  which  rhythmical  irre- 
gularity of  breathing  has  been  always  found  associated  is  athero- 
matous or  calcareous  change,  with  dilatation  of  the  arch  of  the 
aorta,  involving  loss  of  elasticity  in  its  walls.      I  think  these 

1  The  Dublin  Journal  of  Medical  Science,  vol.  Iviii.  p.  519,  1874. 

2  lUd.,  p.  521. 

3  Jahrbuch  fur  Kinderheilkunde  und  physische  ErziehvMg,  neue  Folge.  viii. 
Jahrgang,  S.  420,  1875. 

*  Norsk  Magazin  for  LcBgevidenskaben,  iii.  Raekke,  v.  Bind,  S.  255,  1875. 
'  The  Diseases  of  the  Heart  and  of  the  Aorta,  p.  632,  1875. 


]88».]  niENOMENA   IN   CHEYNE-STOKES   EESPIRATION.  691 

changes  supply  the  conditions  of  a  rational  theory  of  the  pheno- 
menon. During  the  period  of  greatest  tranquillity  of  the  heart's 
action,  viz.,  in  sleep  or  repose,  the  systemic  capillary  circulation 
fails,  from  want  of  the  contributory  aid  rendered  in  health  by  the 
elastic  reaction  of  the  aorta.  Hence  arises  a  suspension  of  tissue- 
respiration,  hesoin  de  respirer,  and  accelerated  or  suspirious  breath- 
ing, as  shown  by  the  experiments  of  Flint  already  referred  to. 
Accelerated  respiration  must  strengthen  capillary  circulation ; 
first,  through  the  lungs,  and  then  through  the  tissues  of  the 
body  generally,  by  quickening  the  action  of  the  heart  and  in- 
creasing its  force.  In  proportion  as  the  systemic  capillary 
circulation  becomes  established,  the  hesoin  de  respirer  is  less 
urgent,  and  respiration  gradually  subsides,  till  a  period  of 
apnoea  arrives.  The  descent  of  respiration  below  the  normal 
standard  would  seem  to  arise  from  its  previous  excessive  activity 
and  the  exhaustion  of  the  patient.  Now,  again,  comes  a  period  of 
feeble  action  of  the  heart,  and  failure  of  capillary  circulation,  with 
its  consequence  of  paroxysmal  breathing.  That  imperfect  circula- 
tion of  arterial  blood  in  the  respiratory  centre  contributes  in  a 
special  manner,  and  in  a  great  degree,  to  the  production  of  the 
respiratory  derangement  I  have  no  doubt ;  but  the  effect  of  this 
is  not  easily  distinguished  from  that  of  a  want  of  oxygen  in  the 
tissues  of  the  body  generally."  Hay  den  also  states  that  he  has 
not  observed  marked  alterations  in  the  rate  of  the  cardiac  pulsa- 
tions with  the  different  phases  of  the  phenomenon ;  only,  "  as  in 
one  or  two  cases,  a  slight  acceleration  during  the  period  of  dyspnoea, 
and  a  gradual  decline  in  that  of  descent,  till  a  minimum  rate  was 
reached  on  the  accession  of  apnoea." 

Hazard^  records  the  case  of  a  gouty  lawyer,  aged  54,  who  met 
with  injuries  in  a  railway  accident  at  the  age  of  32  ;  these  caused 
paraplegia,  from  which  there  was  only  partial  recovery.  A  blow 
on  the  head  when  48  years  of  age  impaired  all  his  powers,  and,  in 
addition  to  some  mental  symptoms,  there  was  after  this  date  such 
evidence  of  a  weak  circulation  as  a  frequent  and  irregular  pulse, 
cyanosis,  and  dyspnoea.  When  seen  he  had  weakness  of  both 
cardiac  sounds  without  any  symptom  of  valvular  disease,  and  soon 
afterwards  symmetrical  gangrene  of  both  feet  set  in,  with  absence 
of  pulsation  in  any  of  the  vessels  of  the  lower  extremities  below 
Scarpa's  triangle.  The  patient  had  a  great  tendency  to  fall  asleep, 
and  when  he  dozed  Cheyne-Stokes  respiration  appeared.  He  died 
from  gradual  extension  of  the  gangrene  upwards,  and  unfortunately 
no  post-mortem  examination  was  obtained.  The  author's  diagnosis 
was  fatty  heart  and  thrombosis  of  the  arteries  of  the  lower  ex- 
tremities. He  enters  into  a  long  physiological  argument  without 
reaching  very  definite  conclusions  with  regard  to  the  causation  of 
the  respiratory  rhythm. 

^  St  Louis  Clinical  Record,  vol.  ii.  p.  54,  1875. 


692  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION,  [FEB. 

Glaus'  entered  upon  a  criticism  of  Filehne's  theory,  based  upon 
the  observation  of  two  cases  under  his  care.  The  first  part  of  his 
paper  is  historical,  entering  fully  into  the  controversy  between  Traube 
and  Filehne,  and  laying  special  stress  on  the  statements  made  by 
the  latter  in  regard  to  the  oscillation  of  the  blood-pressure  seen 
when  the  vagi  are  intact,  and  absent  when  these  have  been 
divided.  He  then  describes  a  case  in  which  nitrite  of  amyl  had 
no  effect  on  the  periodicity  of  the  respiration,  which  he  tries 
to  explain  away  by  supposing  that  in  Filehne's  case  the  abnormal 
irritability  of  the  vaso-motor  centre  was  less  pronounced  than  in 
his  own.  He  will  not  allow  that  there  is  any  evidence  in  favour 
of  the  view  that  the  cause  of  the  phenomenon  lies  in  any  change 
of  the  quantity  of  blood  supplied  to  the  respiratory  centre.  From 
sphygmographic  tracings,  Glaus  concludes  that  there  is  an  increase 
of  blood-pressure  at  the  end  of  the  pause  and  beginning  of  the 
period  of  respiration,  with  a  return  to  the  normal  pressure  during 
the  period  of  breathing  and  beginning  of  the  pause,  and  that  there 
is  an  increase  of  vascular  contraction  during  the  pause.  He  there- 
fore supports  Filehne's  theory  as  to  the  cause  of  the  phenomenon. 
In  a  postscript  to  the  paper  the  author  narrates  a  second  case,  in 
which  one  inhalation  entirely  removed  the  periodic  character  of 
the  breathing,  while  a  second  administration  only  partially  modified 
its  type.  These  results,  however,  he  considers  as  being  in  favour 
of  the  theory  to  which  he  appears  to  have  been  predisposed. 

In  an  elderly  patient,  who  died  apparently  from  cardiac  failure, 
>e  Wette^  watched  the  phenomena  of  Gheyne-Stokes  breathing 
for  thirteen  days,  and  after  a  brief  description  of  the  case,  he  refers 
to  Traube's  theory. 

Eoss^  describes  the  occurrence  of  Gheyne-Stokes  breathing  after 
the  hypodermic  administration  of  half  a  grain  of  morphine  to  an 
intemperate  person  of  40,  who  was  found  in  convulsions  almost 
entirely  confined  to  the  left  side,  with  pupils  of  natural  size.  After 
the  use  of  the  morphine  the  convulsions  ceased  and  the  pupils 
became  contracted,  while  typical  Gheyne-Stokes  breathing  made 
its  appearance.  The  author  notes  that  during  the  pause  in  the 
respiration  the  limbs  become  rigid,  and  again  relax  when  the 
breathing  begins.  This  type  of  breathing  made  its  appearance 
within  four  and  a  half  hours  of  the  time  of  the  administration  of 
the  morphine,  it  remained  for  about  six  hours,  and  ceased  five  hours 
before  death.  The  thoracic  organs  presented  no  abnormal  symptom, 
and  the  urine  was  healthy.  At  the  post-mortem  examination  the 
various  organs  of  the  body  were  found  to  be  perfectly  healthy. 

{To  he  continued.) 

1  Allgemeine  Zeitschrift  fiir  Psychiatrie  und  psychischgerichtliche  Medicin, 
xxxii.  Band,  S.  437,  1875. 

2  Correspondeiiz-Blatt  fiir  schweizer  Aerzte,  vi.  Jahrgang,  S.  140,  1876. 

3  Ganada  Medical  and  Surgical  Journal,  vol.  v.  p.  544,  1876. 


1889.]  PLEURO-PNEUMONIA   AND   TUBERCULOSIS.  693 

IL— NOTES  ON  REPORT  OF  THE  DEPARTMENTAL  COM- 
MITTEE APPOINTED  TO  INQUIRE  INTO  PLEURO-PNEU- 
MONIA  AND  TUBERCULOSIS  IN  THE  UNITED  KINGDOM. 

By  Dr  Peel  Ritchie,  Vice-Pres.  Med.-Chirurg.  Society,  Pres.  R.C.P.  Ed.,  etc., 

F.R.S.E. 

{Read  before  the  Medico-Chirurgical  Society  of  Edinburgh,  7th  November  1888.) 

(Continued  from  page  624.) 

Notes  on  the  Ekport. 

The  Departmental  Committee  was  appointed  to  inquire  into  and 
report  upon  the  nature  and  extent  of  Pleuro-Pneumonia  in  the 
United  Kingdom,  and  the  effects  of  Inoculation  and  other  Pre- 
ventive Measures  on  that  Disease ;  also  to  inquire  into  the  nature 
and  extent  of  Tuberculosis  in  the  United  Kingdom,  and  the  means 
to  be  adopted  to  arrest  its  progress.  Of  course,  as  regards  the 
latter,  it  is  from  the  animal  rather  than  the  human  side  it  is 
considered. 

The  Committee  consisted  of  seven  members,  and  Mr  Eichard 
Dawson  was  appointed  to  act  as  secretary.  Mr  J.  Naper  was 
originally  named  a  member,  but  being  unable  to  attend,  another 
member  was  nominated.  The  following  were  the  members : — 
Jacob  Wilson,  Esq.,  was  elected  chairman  ;  Sir  G.  Macpherson 
Grant,  Bart. ;  J.  Bowen  Jones,  Esq. ;  P.  Stirling,  Esq. ;  Victor 
Horsley,  Esq.,  F.RC.S. ;  Professor  Brown,  C.B.,  of  the  Brown 
Institute  ;  Lord  Cloncurry.  They  were  appointed  on  16th  April 
1888  by  Lord  Cran brook. 

The  Committee  commenced  taking  evidence  on  the  17th  April, 
and  continued  its  meetings  from  time  to  time  up  to  the  4th  of 
June.  During  that  interval  it  sat  on  seventeen  days,  and  exa- 
mined 44  witnesses.  Of  these,  13  represented  England,  16  were 
from  Scotland,  6  from  Ireland,  6  were  Colonial — from  the  Cape 
Colony,  New  South  Wales,  Victoria,  and  Natal.  One  of  these  had, 
however,  been  previously  resident  in  New  Zealand  ;  two  were 
officials  connected  with  the  Agricultural  Department  of  the  Privy 
Council ;  whilst  one  was  foreign,  a  Government  veterinary  surgeon 
from  the  Hague,  Holland.     Arranged  according  to  designation : — 

1.  Justice  of  Peace,  ....  1 

2.  Representative  of  Local  Authority,     .  .  1 

3.  Chief  Constable,  ....  1 

4.  Officers  of  Health,       ....  2 

5.  Inspectors  Agricultural  Department  P.  C,      .  2 

6.  Veterinary  Inspectors,  ...  4 

7.  „  Professors,  ...  2 
„  Surgeons,  British,  4 )  e 
,,                  „         Foreign,  1  j        ' 

9.  Medical  Experimenter  for  Local  Government  Board,  1 


694 


DR   PEEL    UITCIilK   ON 


[fkb. 


10.  Physician, 

11.  President  Shorthorn  Society, 

12.  Landowner, 

13.  Stockowners,  Colonial, 

-,    f  Stock-dealers,  2) 

\  Stock-dealer  and  farmer,    1  J 

15.  Farmers, 

16.  Dairymen  and  cowkeepers, 

17.  Superintendents,  |  ^odel  Fa^m,  1  } 


The  Report  consists  of  two  parts :  1.  The  Eeport ;  2.  The 
Evidence. 

The  subjects  remitted  to  the  Committee  were — Pleuro-Pneu- 
monia :  its  Nature,  Extent,  Effects  of  Inoculation,  and  other  Pre- 
ventive Measures.  This  forms  the  first  part  of  the  Report,  with 
which,  as  a  medical  society,  we  have  nothing  to  do.  Tuberculosis 
(Animal) :  its  Nature  and  Extent  in  the  United  Kingdom,  and  the 
Means  to  be  Adopted  to  Arrest  its  Progress,  forms  the  second  object 
of  the  Committee's  inquiry,  and  it  is  with  it  we,  as  a  Society,  are 
interested.  Of  the  44  witnesses,  27  gave  information  of  varying 
importance  on  tuberculosis,  17  upon  pleuro-pneumonia  alone. 


The  Report  on  Tuberculosis  considers,  first,  the  Nature  of  the 
Disease. 

The  nomenclature  introduces  the  subject  of  the  Report,  and 
after  an  examination  of  the  various  tubercular  diseases,  it  pro- 
ceeds,— "  We  now  know  for  certain  that  they  are  all  forms  of  one 
and  the  same  process,  and  caused  by  a  microbe,"  which  "  forms 
the  poison  or  virus  of  the  disease." 

The  discovery  that  inoculation  of  the  virus  into  the  lower 
animals  is  capable  of  producing  the  malady  is  assigned  to  Klencke 
in  1843,  but  that  Villemin  in  1865  first  placed  it  on  a  firm  basis ; 
"  the  nature  of  the  poison  itself  remained  unknown  until  it  was 
discovered  by  Koch,  in  1881,  to  be  a  rod-shaped  microbe."  The 
microbe  is  then  defined,  the  greater  vitality  of  the  spores  is  dwelt 
upon,  and  the  importance  of  it  and  the  viability  of  the  rods  are 
pointed  out, — "  Since,  if  the  mucus,  or  saliva,  or  expectoration  of 
an  animal  or  human  being  suffering  from  tuberculosis  be  dropped 
upon  the  ground,  flooring,  or  furniture  of  a  room  or  shed,  it  is 
obvious  that  such  secretions  are,  in  proportion  to  the  effect  which 
exposure  at  the  temperature  of  the  air  and  drying  may  have  in 
destroying  the  organisms  and  their  spores,  a  source  of  danger  to 
other  animals  or  human  beings  who  may  accidentally  take  up 
the  poison." 

The  effect  of  temperature  is  next  reviewed — that  most  favourable 
to  the  growth  of  the  microbe  being  the  ordinary  heat  of  a  warm- 
blooded animal,  from  about  98°-5   to  100°-5  Fahrenheit.     At  82° 


1889.]  PLEURO-PNEUMONIA   AND   TUBERCULOSIS.  695 

Fahr.  growth  ceases,  but  this  degree  does  not  kill  the  microbe.  If 
"  kept  at  a  temperature  of  about  107°"5  Fahr.  for  several  weeks, 
the  organism  gradually  becomes  exhausted,  and  dies."  The  effect 
of  drying  upon  the  microbes  is  mentioned  ;  few  resist  desiccation  ; 
but  from  experiments  made  upon  expectoration  containing  bacilli, 
it  has  been  proved  that  such  expectorations  may  be  kept  for 
several  months  successively  dried  and  moistened,  and  then,  when 
inoculated  into  animals,  the  bacilli  are  found  not  to  have  been  killed, 
as  "  they  have  actively  produced  the  disease." 

It  is  pointed  out  that  tubercular  discharges  in  this  climate  may 
remain  virulent  for  a  long  time ;  and  stalls  and  sheds,  unless 
thoroughly  cleansed,  be  a  source  of  danger. 

The  order  of  liability  of  domesticated  animals  is  given  thus  : — 
1.  Man  stands  first ;  then  2,  milch  cows  ;  3,  fowls ;  4,  rodents ;  5, 
pigs ;  6,  goats ;  7,  sheep ;  8,  horses ;  9,  carnivora,  i.e.,  dogs,  cats, 
etc.  (very  rarely).  "  From  this,"  the  Eeport  adds,  "  it  appears  that 
the  organism  grows  most  readily  in  those  animals  which  are 
omnivorous  and  herbivorous," — a  summing  up  which,  perhaps, 
requires  a  little  modification.  From  the  evidence,  and  also  sub- 
sequently in  the  Eeport,  a  distinction  as  to  frequency  of  tuber- 
culosis is  shown  to  exist  between  stall-fed  cows  and  field  cattle, 
but  in  the  foregoing  list  this  is  not  alluded  to.  The  greater  liability 
of  the  female  sex  and  young  animals  to  become  affected  is  also 
mentioned. 

Five  predisposing  conditions  are  next  reviewed  : — 

1.  Starvation,  as  causing  degeneration  of  tissue  and  diminishing 
resistance  to  microbe  growth. 

2.  Deficiency  of  oxygen  hy  had  ventilation.  This,  whilst  predis- 
posing the  one  animal,  also  favours  the  transmission  of  the  virus 
to  another. 

3.  Exhausting  secretions^  e.g.,  prolonged  lactation.  "  The  constant 
loss  of  the  fat,  albumen,  and  salts  contained  in  the  milk  "  produce 
"  those  degenerative  changes  which  reduce  the  vital  resistance  of 
the  animal." 

4.  Possibly  heredity  (afterwards  referred  to),  an  influence  "  attri- 
buted by  some  to  the  transmission  from  parent  to  offspring,  not  of 
the  actual  virus,  but  of  a  condition  of  tissue  which  is  peculiarly 
favourable  to  the  development  of  that  organism." 

5.  Certain  foods  {asserted,  but  very  doubtful).  "  Some  foods,  i.e., 
grains,  etc.,  have  been  imagined  to  favour  the  occurrence  of  tuber- 
culosis, but  this  is  extremely  problematical."  Although  this  is 
the  deliverance  of  the  Committee,  I  remain  of  the  opinion  I  ex- 
pressed, that,  looking  to  the  drain  from  the  milch  cow's  system, 
feeding  the  animal  upon  the  kinds  of  food  which  favour  the  flow 
of  milk,  unless  attention  is  paid  to  also  supplying  a  compensating 
amount  of  blood  and  flesh  producing  food,  cannot  but  aid  in  the 
production  of  such  degenerative  changes  as  to  reduce  the  vital 
resistance  of  the  animal. 


696  DR   PEEL   RITCHIE   ON  [FEB. 

The  modes  in  which  the  virus  or  microbe  enters  the  body  have,  it  is 
stated,  been  proved  to  be  the  following : — 

1.  Inhalation,  into  the  air  passages  and  lungs. 

2.  Swallowing,  into  the  alimentary  or  digestive  system. 

3.  Direct  introduction^  into  the  subcutaneous  or  submucous  tissue 
by  means  of  a  scratch  or  cut  or  sore  in  the  skin  or  mucous  membrane. 

It  is  also  supposed  to  be  directly  transmitted  by  4.  Heredity. 

Inhalation. — From  "  the  fact  that  the  signs  of  disease  are  most 
commonly  found  in  the  lungs,  inhalation  would  appear  to  be  the  com- 
monest way  in  which  the  disease  is  contracted."  The  result  of  com- 
parative experiments  has  tested  this  ;  and  the  Report  continues  : — 
"  The  results  of  these  experiments  have  been  almost  invariably 
positive,  the  animals  breathing  such  infected  air  rapidly  succumb- 
ing to  the  disease."  For  my  own  part,  I  can  readily  believe  the 
results  of  experiments  so  conducted ;  but,  unless  the  infecting 
animal's  lungs  were  in  a  very  advanced  stage  of  disease,  I  cannot 
say  that  I  can  quite  accept  this  statement  as  altogether  correct. 
The  deduction  is  that  "  cohabitation  of  the  diseased  and  healthy 
animals  is  a  fertile  source  of  spread  of  the  malady." 

Swallowing  is  also  supported  by  numerous  experiments.  The 
virus  in  mucus,  saliva,  milk,  portions  of  "  diseased  tissues  and  cul- 
tures of  the  bacilli,  have  been  swallowed  by  calves,  pigs,  sheep, 
rodents,  fowls,  etc.,  with  the  effect  that  the  disease  has  fatally 
followed  the  ingestion."  It  is  added  that  "  it  is  evident  the 
digestive  fluids  do  not  necessarily  exert  an  injurious  influence 
upon  the  poisonous  bacilli."  I  would  here  refer  to  the  evidence 
(p.  256)  of  Mr  A.  Lingard  for  account  of  the  case  described  by  Dr 
Lamalleree  in  the  Gazette  Medicate  of  loth  Aug.  1883,  in  which 
tuberculosis  was  not  only  transmitted  from  man  to  fowls  by  their 
consuming  the  expectoration  of  a  phthisical  woman  (who,  it  is 
presumed,  had  been  infected  by  her  phthisical  husband),  but  also 
was  transmitted  from  them  to  a  previously  healthy  woman,  who 
within  a  period  of  three  months  had  eaten  ten  or  twelve  of  the 
fowls  which  had  died  of  tuberculosis. 

Direct  introduction. — The  microbes  make  their  way  to  the 
glands  ;  these  become  diseased ;  the  microbes  pass  by  the  lymph- 
atics to  the  veins,  and  the  virus  is  distributed  through  the  body. 
"  Undoubted  instances  have  been  laid  before  us  of  such  inoculation 
occurring,"  "  and  one  or  two  stated  in  the  evidence  in  which  a 
bull  has  given  the  disease  to  cows ;  and  the  converse  has  also  oc- 
curred, namely,  that  a  bull  has  contracted  the  disease  from  cows." 

Heredity. — Tlie  predisposition  through  the  "  tissues  of  one 
particular  breed  or  race "  being  "  favourably  disposed  to  nourish 
the  tubercle  bacillus  "  has  been  already  referred  to ;  but  "  whether 
the  bacillus  is  actually  contained  in  the  ovum  or  spermatozoon  "  is 
considered.  The  statements  by  Baumgarten,  that  he  has  "  observed 
the  bacillus  in  the  rabbit  within  the  ovum,"  and  that  other  ob- 
servers have  seen  them  mingled  with  active  spermatozoa,  are  given. 


1889.]  PLEURO-PNEUMONIA   AKD   TUBEKCULOSIS.  697 

In  support  of  the  transmission  theory,  the  case  of  Professor  Johne  of 
Dresden  is  referred  to,  in  which  the  infected  intrauterine  7  months' 
calf  of  a  tubercuhir  cow  is  mentioned,  and  it  is  remarked,  "  Similar 
intrauterine  infection  has  been  shown  to  have  been  more  than  prob- 
able in  the  human  being  ; "  but  it  is  also  added,  "  Against  this  view 
of  the  infection  of  tlie  ovum  and  embryo  it  has  been  suggested 
tliat  the  disease-producing  influence  of  the  bacillus  would  prevent 
the  ovum  arriving  at  maturity."  Stock  breeders  have  discovered 
the  risk  "  of  breeding  from  tubercular  stock."  In-breeding,  as 
giving  rise  to  tuberculosis,  is  held,  as  was  to  be  expected,  to  be 
erroneous ;  but  as  predisposing  to  infection,  if  the  virus  is  intro- 
duced into  the  herd,  is  held  as  probable. 

The  Mode  of  Attach  and  Distribution  of  the  Disease  vjtthin  the  Body. 

The  disease  may  attack  the  body  of  an  animal  as  acute  or 
general  or  miliary  tuberculosis,  or  more  chronically,  in  tlie  first 
instance,  as  local  tuberculosis,  becoming  by  means  of  the  lymphatic 
glands  subsequently  distributed  over  the  body.  The  local  is  held 
to  be  more  common  in  man  than  in  the  lower  animals ;  and  the 
lieport  continues, — "Tlie  distribution  of  the  disease  in  the  body  is 
difficult  to  connect  with  any  special  mode  of  introduction  of  the 
virus,  save,  perhaps,  inhalation."  This  is  to  me  the  more  difficult  to 
accept  when  the  next  paragraph  states, — "  Undoubtedly  in  cattle 
the  lungs  and  pleurse  and  the  serous  membranes  generally  are  the 
favourite  seats  of  the  malady,  any  and  each  of  the  other  organs 
being  occasionally  affected."  In  pigs,  the  cervical  glands;  in  rodents, 
the  spleen,  liver,  lungs,  and  bones ;  in  fowls,  the  nose,  mouth,  and 
spleen ;  in  horses,  the  glands ;  and  in  man,  the  glands,  the  lungs, 
the  joints,  and  the  nervous  system — are  stated  to  be  the  commonly 
affected  parts. 

As  the  tubercle  bacillus  appears  to  grow  best  where  the  circula- 
tion is  least  vigorous,  it  is  held  that  to  this  is  due  the  predilection 
for  the  lungs,  spleen,  and  joints.  Mr  Lingard  in  his  evidence  states 
that  he  found  the  bacillus  at  an  early  period  of  infection  in  the 
marrow  of  the  bones  (shown  also  by  Professor  M'Call),  and  before 
other  sign  of  their  presence  was  observed.  This  is  mentioned  in 
connexion  with  the  question  of  the  use  of  tubercular  meat  as  food. 
Evidence  was  given  that  though  rarely  the  flesh  may  be  affected, 
and  that  ordinary  cooking  may  not  be  sufficient  to  destroy  the 
bacilli,  for  they  may  also  be  in  the  blood,  and  that,  therefore,  the 
chance  of  their  presence  "  is  too  probable  to  ever  allow  the  flesh 
of  a  tubercular  animal  being  used  for  food  under  any  circum- 
stances, either  for  man  or  the  lower  animals." 

The  appearance  of  tubercles,  in  the  tissues,  and  according  to  rate 
of  increase  and  the  changes  the  nodules  m  ly  undergo,  are  then 
described.  The  presence  of  bacilli  in  the  secretions  from  diseased 
organs  is  next  considered;  and  the  Keport  continues, — "  Of  these  it 
is  obvious  that  the  fact  of  milk  being  infected  is  of  primary  ira- 

EDINBURGH   MED.    JOURN..   VOL.    XXXIV.— NO.    VIII,  4T 


998  DU   PEKL    UITGIIIE    ON  [FEB. 

portance  to  the  health  of  both  animals  and  of  men,  since  milk  has 
been  proved  both  to  contain  the  bacilli  and  to  infect  the  lower 
animals,  e.g.,  calves,  pigs,  etc. ;  while,  unfortunately,  it  is  becoming 
abundantly  clear  that  by  the  same  method  of  transmission  of  the 
virus  the  disease  is  communicated  to  the  human  being."  It  will  be 
observed  that  the  question  as  to  whether  the  udder  is  the  part 
affected  or  not  is  not  entertained.  If  the  cow  is  tubercular  in  the 
view  of  the  Committee,  both  its  flesh  and  its  milk  are  to  be  re- 
garded as  unfit  for  human  or  animal  consumption.  One  of  the 
points  calling  for  further  experimental  observation,  the  infectivity 
or  non-infectivity  of  milk  from  a  cow  without  udder  lesions,  is 
thus  set  aside,  but  it  is  a  question  of  much  importance  still  un- 
settled. In  my  statement  I  took  the  view  that  it  was  only  when 
there  was  udder  lesion  that  the  Society  had  evidence  of  evil  result. 
The  general  symptoms  of  tuberculosis,  and  the  want  of  them 
in  local  slow-growing  cases,  leading  to  difficulty  of  recognition,  are 
touched  on,  and  the  characters  of  the  symptoms  ultimately,  are 
described,  and  the  evidence  to  be  gained  from  physical  examination 
of  the  chest ;  and  this  section  concludes  with  the  statement, — 
"  The  disease  in  the  lower  animals  ahvays  terminates  fatally." 

Frequency  of  Proportionate  Occurrence  among  Animals  and  Men. 

The  calculated  death-rate  from  the  various  processes  set  up  by 
the  tubercular  bacillus  is  stated  from  the  statistics  of  the  registers 
of  different  countries  to  be  "  10  to  14  per  cent,  of  all  deaths  among 
human  beings."  In  Paisley  it  is  said  the  death-rate  has  been  as 
high  as  17'5.  In  Edinburgh  the  percentage  of  animals  killed  and 
found  tubercular  is  very  low ;  yet,  according  to  the  last  report  of 
the  Eegistrar-General  for  Scotland,  the  deaths  from  phthisis  alone 
in  Edinburgh  were  11*8  per  cent,  of  the  total  deaths,  and  from 
all  tubercular  diseases  16-4.  By  tlie  same  returns  for  Scotland 
the  deaths  from  phthisis  number  107o,  and  from  tubercular  dis- 
eases 14'55,  which  is  above  the  maximum  average  given  above. 
Could  we  obtain  accurate  returns  of  the  tubercular  cattle  killed, 
it  would  be  interesting  to  trace  their  relation  to  the  human  tuber- 
cular death-rate  ;  and  I  hope  to  be  able  to  follow  up  this  subject, 
now  that  my  attention  has  been  called  to  it.  Amongst  animals 
the  proportionate  occurrence  has  not  been  so  clearly  made  out. 

In  Dublin  the  animals  slaughtered  were  at  the  rate  of  4*9  per 
cent. ;  and  from  the  evidence  the  rate  varies  from  50  per  cent,  near 
Glasgow  (Q.  4262) ;  37-5  per  cent.  Liberton,  near  Edinburgh 
(Q.  7620) ;  30  per  cent,  in  Paisley  and  Glasgow  stock  (Q.  5371) ; 
25  per  cent.  Ayrshire  dairy  cows  (Q.  835) ;  4*5  per  cent.  Victoria 
(Q.  5582) ;  3-5  per  cent.  Lanarkshire  (Q.  5360) ;  to  "2  per  cent,  of 
all  animals,  cows,  oxen,  etc.,  killed  at  Edinburgh  (Q.  7684) — that 
is,  97  condemned  carcases  in  Edinburgh  out  of  40,421  animals 
killed.     It  would  appear  to  me  that  the  percentages  are  given 


1889.]  PLEURO-PNEUMONIA   AND    TUBERCULOSIS.  699 

upon  results  from  too  small  numbers — the  50  per  cent,  statement 
being  based  on  the  deaths  of  13  out  of  25  milch  cows. 

In  Germany  the  proportion  among  cattle  slaughtered  appears  to 
vary,  from  tlie  Eeport,  from  1'5  to  20  per  cent.,  according  to  district. 
Tliese  variations  are  explained  by  the  Committee  thus :  The  low 
percentages  are  those  for  open-air  fed  herds,  the  high  death-rates 
among  dairy  cattle  cohabiting  in  sheds. 

The  frequency  of  tuberculosis  amongst  fowls  has  also  attention 
directed  to  it  as  not  being  generally  known,  and  that  both  observa- 
tion and  experiment  have  shown  that  the  fowl  contracts  the  disease 
from  man  by  swallowing  the  expectorated  bacilli,  and  again  forms 
a  vehicle  for  its  transmission  to  man  and  the  lower  animals. 

Several  authorities  consider  the  disease  amongst  cattle  is  on  the 
increase,  but  the  Committee  consider  this  is  doubtful ;  for  probably 
the  apparent  increase  may  be  due  to  better  recognition,  and  that 
better  hygiene  has  diminished  the  tubercular  death-rate. 

The  Eeport  next  addresses  itself  to  the  question  of 
Remedial  Measures. 

It  says  two  points  are  to  be  borne  in  mind  in  tl)e  consideration  : 
1.  "  That  the  disease  can  be  transmitted  to  man  from  the  lower 
animals,  and  from  man  to  tlie  lower  animals,  by  one  or  other  of 
the  methods  which  we  have  already  discussed,  and  especially  by 
the  ingestion  of  tubercular  diseased  meat  or  milk."  The  last 
clause  has,  of  course,  reference  only  to  the  transmission  of  the 
disease  from  animal  to  man,  or  from  animal  to  animal.  2.  "  That 
it  spreads  from  animal  to  animal." 

After  pointing  out  that  the  first  of  these  is  usually  dealt  with 
under  the  Public  Health  Act,  the  difficulty  in  dealing  with  tuber- 
culosis is  that  "  not  only  is  the  disease  communicated  from  animals 
to  man,  but  also  from  man  to  animals."  Legislation,  therefore, 
which  protects  cattle  from  tuberculosis  must  also  prevent  its  com- 
munication to  man. 

As  curative  treatment  is  so  unsatisfactory,  the  Eeport  indicates 
"  that  legislation  must  follow  the  two  lines  of — 

A.  Prevention ;   B.  Extirpation." 

Under  Preventive  Measures  are  reviewed  the  improved  hygiene  of 
cattle  sheds,  etc.,  as  regards  ventilation,  water  supply,  disinfection 
of  stalls,  etc.  It  points  out  that  although  this  has  been  partly 
met  by  the  Dairy  and  Milk-shops  Order,  that  its  administration  is 
imperfect,  and  "  we  would  suggest  that  it  should  be  much  more 
stringently  enforced,  and  that  veterinary  inspectors  should  be 
given  more  extended  powers  of  entry  into  all  places  where  animals 
are  kept."  The  isolation  of  suspected  animals,  and  prevention  of 
the  flesh  or  milk  of  diseased  animals  being  given  as  food  to  others, 
and  restriction  as  to  fodder,  litter,  and  water,  are  insisted  on. 


700  DK    PEEL    lUTCIIlE    ON  [FEB. 

Ill  England  and  Ireland,  although  the  medical  officer  of  health 
or  inspector  of  nuisances  has  power  to  seize  diseased  animals  in 
open  market,  "  yet  such  seizure  is  rarely  y^erformed  ; "  whilst  the 
veterinary  inspector  has  no  power  to  ])revent  the  sale  or  to  order 
their  slaughter,  since  tuberculosis  is  not  included  in  the  Contagious 
Diseases  (Animals)  Act,  1878,  "  The  Committee  are  very  strongly 
of  opinion  that  power  should  be  given  to  veterinary  inspectors  to 
seize  '  wasters  '  and  '  mincers  '  in  fairs,  markets,  or  in  transit." 

The  risk  of  the  disease  being  imported  the  Committee  does  not 
consider  great  whilst  the  regulations  as  to  slaughtering  and 
keeping  in  quarantine  at  port  continue  ;  but  as  there  may  be 
danger  in  importation  from  countries  exempted  from  slaughtering, 
the  present  rules  are  incomplete.  Another  difficulty  arises  from 
the  failure  of  veterinary  surgeons  to  detect  the  disease  in  the 
early  stages  ;  and  the  Committee  conclude  there  could  have  been  no 
proper  veterinary  examination  in  the  case  of  animals  found  exten- 
sively diseased  after  death,  but  believed  to  be  sound  previously. 

Whilst  the  Eeport  is  satisfied  with  stating  that  "  it  is  highly 
desirable  that  breeders  should,  in  their  own  as  well  as  in  the  public 
interest,  discontinue  breeding  from  tuberculous  stock,"  Professor 
Horsley,  in  a  Supplementary  Report,  states  that,  in  his  opinion, 
"  the  act  of  wittingly  breeding  from  animals  so  affected  should  be 
made  '  an  indictable  offence.'  "  Prosecutions  might  arise  from  the 
"present  state  of  want  of  knowledge"  "  of  the  early  symptoms  and 
physical  signs"  among  cattle-owners,  and  even  veterinary  surgeons. 
He  thinks  that  vexatious  prosecutions  would  be  few,  and  that  as  each 
would  be  tried  "  before  district  magistrates  on  its  own  merits,"  the 
objection  would  not  be  of  much  force. 

This  brings  us  to  the  climax  of  the  Report,  Extirpation. 

Extirpation. — The  Committee  are  of  opinion  that  tuberculosis 
should  be  included  in  the  Contagious  Diseases  (Animals)  Acts,  so 
as  to  provide: — "For  the  slaughter  of  diseased  animals  when  found 
diseased  on  the  owner's  premises."  "  For  tlie  payment  of  com- 
pensation for  the  slaughter  of  such  animals."  "  For  the  seizure 
and  slaughter  of  diseased  animals  exposed  in  faiis,  markets,  etc., 
and  during  transit."  "  For  the  seizure  and  slaughter  of  diseased 
foreign  animals  at  the  place  of  landing  in  this  country." 

On  the  plea  that  tuberculosis  may  exist  without  "  sufficient 
outward  evidence  to  enable  the  owner  to  detect  it,"  and  its  growth 
is  so  slow  "  that  non-notification  of  its  existence,  even  in  a  large 
number  of  cases,  would  do  little  to  nullify  the  stamping-out  effect 
of  the  Act  of  1878,"  notification,  the  Report  decides,  should  not 
be  compulsory.  Professor  Horsley,  again,  differs  from  this  con- 
clusion, and  says  "  that  deliberate  non-notification  should  be  pun- 
ished cannot  be  doubted  by  any  one."  He  then  refers  to  the 
objections, and  continues, — "  As,however,I  consider  that  these  objec- 
tions have  been  already  shown  to  have  no  weight,  I  recommend 
that  both  the  forbiddal  of  the  breeding  from  diseased  animals  and 


1889.]  PLEUHO-PxN'EUMONIA.   AXD    TUBERCULOSIS.  701 

tlie  notification  'of  tlie  disease  should  be  included  in  any  legislation 
for  tuberculosis." 

After  all  the  evidence  laid  before  the  Committee,  the  views 
it  has  taken  of  the  spread  of  tuberculosis  by  the  breath  of  affected 
animals,  and  the  opinion  expressed  regarding  the  presence  of  tuber- 
cle in  animals  presumed  to  be  healthy,  that  they  had  not  been 
submitted  to  proper  veterinary  examination,  it  is  somewhat  sur- 
prising that  notification  should  not  be  made  compulsory.  As 
Professor  Horsley  states,  "  Since  it  is  clear  that  unless  the  veterinary 
inspectors  or  authorities  receive  infoimation  of  occurrence  of 
diseases,  it  is  impossible  to  insure  the  thorough  carrying  out  of 
the  provisions  of  the  Contagious  Diseases  (Animals)  Act;"  and 
with  this  I  agree.  And  as  we  have  taken  so  prominent  a  position 
in  this  question,  it  seems  to  me  that  when  the  next  stage  is  reached 
we  ought  again  to  step  forward  and  petition  in  favour  of  the  views 
expressed  by  Professor  Horsley  being  made  impei'ative.  They 
both  more  strongly  enforce  the  action  to  be  taken  for  the  extirpa- 
tion of  tuberculosis  in  cattle. 

The  Report  considers  that  inspectors  should  have  the  same  powers 
regarding  animals  suffering  from  tuberculosis  as  from  pleuro- 
pneumonia. The  Committee  are  of  opinion  that  the  slaughter  of 
diseased  animals  would  go  far  to  stamp  out  tuberculosis  ;  though, 
doubtless,  owing  to  heredity,  the  process  would  be  gradual.  Another 
argument  in  favour  of  slaughter  is  the  frequency  with  which  pleuro- 
pneumonia and  tuberculosis  co-exist,  and  are  mistaken  the  one  for 
tlie  other. 

Some  of  the  arguments,  it  must  be  confessed,  seem  to  imply  that 
veterinary  education  does  not  sufficiently  progress ;  but  probably 
what  the  Committee  feel  is,  that  often  these  animals  are  not  sub- 
mitted to  veterinary  inspection  till  they  are  exposed  or  after 
slaughter,  and  hence  arises  the  difficulty.  Seeing,  however,  if  the 
Eeport  is  adopted  and  carried  out  by  the  Privy  Council,  the  future 
of  tuberculosis  is  reduced  to  a  question  of  diagnosis,  the  improved 
instruction  of  veterinary  surgeons  and  inspectors  must  follow,  and 
more  allowance  in  the  recommendations  should  be  made  for  the 
improvement  of  veterinary  accuracy. 

The  last  clauses  of  the  Report  consider  the  compensation  to  be 
given  the  owner  for  the  compulsory  slaughter  of  his  animal,  but 
that  is  not  a  question  which  concerns  us  professionally. 

The  Committee  conclude  by  expressing  their  belief  that,  if  their 
"  recommendations  be  firmly  carried  out,  pleuro-pneumonia  may 
within  a  moderate  period  be  exterminated  in  this  country  ;  "  *'  and 
although  we  cannot  dare  to  indulge  in  such  sanguine  expectations 
with  regard  to  tuberculosis,  we  still  venture  to  hope  that  much 
may  be  done  to  reduce  its  extent,  and  to  minimize  a  disease  so 
dangerous  alike  to  animals  and  to  mankind." 

President  and  Gentlemen,  I  have  concluded  my  revievir  of  this 


702  DR. PEEL   hlTCIIlE   ON  [I'KB. 

Eeport.  You  will  doubtless  agree  with  me  in  regarding  it  as  a  very 
able  one,  and,  farther,  that  its  conclusion  as  to  Remedial  Measures 
could  be  no  other  than  it  is.  You  must  remember  that  the  Com- 
mittee were  appointed  for  practical  rather  than  scientific  ends,  and 
that,  as  expressed  by  Professor  Brown  (7644,  5),  "  under  our  Acts 
(Contagious  Diseases  Animals)  we  have  absolutely  no  power  what- 
ever to  deal  with  the  disease  solely  on  the  ground  that  we  might 
take  measures  to  prevent  its  extension  to  human  beings."  "  We 
are  bound  to  show  that  our  measures  have  reference  mainly  to 
the  prevention  of  the  extension  of  the  disease  among  the  lower 
animals." 

The  evidence  showed  that  tuberculosis  was  contagious,  that  it 
could  be  transmitted  from  one  animal  to  another,  from  man  to 
animals,  and,  although  seemingly  of  less  importance  to  this  Com- 
mittee after  the  opinion  I  have  quoted,  from  animals  to  man.  You 
sent  your  two  delegates  to  give  evidence  as  to  your  views.  I 
endeavoured  to  do  my  part,  which  was,  if  I  may  say  so,  to  express 
the  more  scientific  side  of  the  Society's  views.  I  supported  the 
identity  of  the  disease  in  animals  and  man,  its  transmissibility, 
and  the  scientific  doubts  existing  in  the  minds  of  many,  and  the 
necessity  for  experiments  conducted  on  a  large  or  extended  scale, 
such  as  only  could  be  done  by  Imperial  action.  I  viewed  the 
question  from  the  human  side. 

Your  other  representative  viewed  it  from  the  animal  or,  in  this 
case,  the  practical  side.  In  order  to  deal  with  the  diseased  animals, 
he  supported  the  other  views  the  Society  brought  forward,  that  the 
animal  suffering  from  tuberculosis  was  injurious  to  its  fellows,  as 
well  as  to  humanity,  and  pleaded  that  the  disease  should,  for 
various  practical  reasons,  be  classed  among  the  contagious  diseases 
of  animals. 

The  scientific  inquiry  for  the  Committee's  purpose  had  gone  far 
enough.  The  further  points  we  wanted  to  have  cleared  up  by 
extended  investigation,  in  their  eyes,  were  unnecessary.  If  the 
milk  was  injurious,  whether  it  came  from  a  tuberculous  udder  or 
a  tuberculous  cow,  was  of  no  consequence  from  their  point  of  view. 
Whether  the  flesh  of  an  animal  was  capable  of  producing  disease 
or  not,  if  tubercle  existed  in  other  parts  of  the  body,  was  of  no 
consequence.  To  trace  the  effects  of  milk  from  a  cow  found  to  be 
tubercular  did  not  come  within  their  range  of  inquiry.  If  butter 
or  cheese  made  from  the  milk  of  a  tubercular  Ayrshire  cow  was 
the  means  of  disseminating  tubercle  was  not  the  question  of  im- 
portance with  them.  That  a  bull  with  tubercular  disease  could 
directly  convey  disease  to  the  cow,  and  that  the  cow,  on  the 
other  hand,  with  a  tubercular  uterus  could  convey  disease  to  the 
bull ;  that  a  cow  with  tubercular  uterus  was  unfit  for  breeding  ; 
that  cohabitation  in  an  insanitary  byre  was  injurious ;  that  pigs  fed 
on  tubercular  milk  had  the  disease  produced  in  them — were  of  chief 
importance.   These  things  were  held  proved;  and  without  going  into 


1889.]  PLEURO-PNEUxMONIA   AND   TUBERCULOSIS.  703 

the  nicer  questions  I  liave  hinted  at  as  subjects  for  further  experi- 
mental research,  they  put  an  end  to  all  questions,  for  if  tubercle 
exists  in  the  animal,  the  bacilli  are  probably  in  the  blood,  and 
they  therefore  declare  a  tubercular  animal,  whether  locally  or 
generally  affected,  to  be  dangerous  l)oth  in  its  living  and  its 
dead  state,  and  stop  further  inquiry  after  the  presence  of  tubercle 
is  proved.  For  practical  sanitary  purposes  we  cannot  but  approve, 
but  as  scientific  inquirers  we  may  possibly  regret  that  so  many 
details  are  left  still  unsatisfied. 


III.— CLINICAL  NOTES  ON  FATTY  TUMOURS  OF  THE 

LARYNX. 

By  P.  M'Bride,  M.D.,  F.R.C.P.E.,  F.R.S.E.,  Surgeon  Ear  and  Throat 
Department,  Koyal  Infirmary,  and  Lecturer  on  Diseases  of  the  Ear  and 
Throat,  Edinburgh  Medical  School. 

{Read  before  the  Medico-Chiriirgical  Society  of  Minburgh,  \^th  December  1888.) 

My  reasons  for  calling  attention  to  lipomata  of  the  larynx  are — 
(1),  that  these  growths  are  of  extreme  rarity;  and  (2),  that  within 
the  last  eighteen  months  I  have  operated  upon  two  cases  of  this 
kind. 

From  a  perusal  of  the  most  recent  literature  on  this  matter, 
including  the  second  edition  of  Gottstein's  Krankheiten  des  Kehl- 
kopfes,  published  this  year,  I  gather  that,  so  far,  only  in  two  cases 
have  fatty  tumours  been  removed  from  the  larynx  intra  vitam,  and 
that  the  operators  have  been  Rruns  and  Schrotter.  In  two  other 
instances  Wagner  and  Tobold  noted  the  presence  of  lipomata  on 
the  dissection  table. 

At  this  juncture  I  should  like  to  turn  aside  for  a  moment  to 
point  out  certain  discrepancies  which  I  have  discovered  in  my 
literary  researches  concerning  a  subject  so  limited  tliat  one  might  at 
.  all  events  expect,  from  those  who  consider  themselves  authorities 
on  laryngeal  diseases,  an  approach  towards  approximate  accuracy. 
Eppinger  (FatJiolof/ische  Anatomie  des  Larynx  unci  der  Trachea,  p. 
205)  quite  correctly  mentions  the  three  examples  which  had  been 
observed  up  to  the  year  1880, — to  wit,  those  of  Wagner,  Tobold, 
and  Bruns.  With  regard  to  Wagner's  case,  he  gives  the  reference 
as  Archiv  filr  Prakt.  Heilkunde,  1872,  p.  108,  and  states,  in  a 
somewhat  aggrieved  tone,  that  the  growth  was  as  large  as  a  hen's 
egg,  and  that  there  is  no  further  account  of  "  its  attachment  and 
relation  to  the  interior  of  the  larynx."  Now  I  have,  shall  I  say, 
verified  this  reference,  and  found  it  in  the  corresponding  part,  not 
of  the  Archiv  f.  prakt.  Hcilkiuule,  but  in  the  Archiv  f.  Heil- 
kunde (1872,  p.  108),  and  I  Imve  further  found  that  the  lipoma 
referred  to  was  attached  "  by  a  thin  broad  base  to  the  middle  line 
of  the  tongue  and  anterior  part  of  the  epiglottis."     This  growth,  I 


70-4  DR   p.   M'BRIDE'S   clinical   notes   on  [FEB. 

may  add,  was  found  in  the  body  of  a  girl  of  thirteen  who 
liad  died  of  smallpox,  and  Wagner  further  mentions  that  she 
was  to  have  been  operated  upon  by  Wendt.  From  this  we 
may,  I  presume,  infer  that  no  immediately  urgent  symptoms 
existed.  Eppinger  also  mentions  Tobold's  case  as  being  described 
in  the  Archiv  f.  Prald.  Heilkuncle,  1872,  p.  422.  I  do  not  know 
whether  such  a  journal  exists,  but  the  Archiv  f.  Heilkunde  (in 
which  the  preceding  case  was  found)  does  not,  at  the  page  named, 
contain  any  reference  to  a  lipoma  of  the  larynx.  So  mucli  for 
Eppinger's  accuracy.  But  if  we  now  turn  to  Schrotter's  paper 
("  Ueber  das  Vorkommen  vor  Fettgewehe  im  Larynx,"  Monatsschrift 
fur  Ohrenheilkiinde,  June  1884),  we  find  exactly  the  same  inac- 
curacies repeated.  In  Gottstein's  work  the  erroneous  references 
are  not  reproduced,  possibly  because  no  exact  references  are  found 
in  the  book,  but  it  is  expressly  stated  that  in  Wagner's  case  the 
point  of  attacliment  is  not  given,  showing  that  no  attempt  can 
have  been  made  to  verify  his  statements  {Die  Krankheitcn  des 
Kehlkopfes,  1888,  p.  149).  Now,  as  I  cannot  find  Tobold's  case 
described  by  any  other  authors  than  those  referred  to,  it  is  not 
surprising  that  I  know  little  about  it,  and  that  also,  for  obvious 
reasons,  I  refrain  from  reproducing  what  little  is  mentioned  by 
these  authorities.  I  have  no  desire  to  act  the  part  of  a  captious 
critic,  but  the  evil  illustrated  by  my  investigations  into  a  subject 
so  limited  as  lipoma  of  the  larynx  is,  I  believe,  widespread. 
Authors  are  too  apt  to  follow  each  other  like  sheep  without  verify- 
ing data,  and  thus,  instead  of  perpetuated  trutli,  we  have  perpetu- 
ated error.  To  grasp  the  whole  of  medical  science  is  impossible 
for  one  man,  but,  on  the  other  hand,  it  is  not  too  much  to  ask  of 
those  who  would  be  our  instructors  and  pioneers  that  they  should 
first  instruct  themselves. 

To  return  to  our  subject,  then,  we  find  that  the  authentic  cases 
of  laryngeal  lipoma,  so  far  as  can  be  ascertained,  are  three 
in  number.  That  recorded  by  Wagner  has  already  been  described. 
In  Bruns'  ^  patient,  who  was  twenty-five  years  of  age,  the  tumour 
grew  from  the  left  half  of  the  posterior  laryngeal  wall,  filled  the 
whole  glottic  aperture,  and  was  removed  by  repeated  use  of  the 
electric  cautery.  Schrotter's  case  {op.  cit.)  was  in  several  respects 
peculiar. 

The  patient,  a  man  of  55,  two  years  before  his  examination, 
began  to  suffer  from  a  tickling  cough.  Fifteen  months  later  he 
began  to  have  the  feeling  of  a  foreign  body  in  the  throat,  and 
eventually  distinct  dyspnoea  with  nocturnal  exacerbations  became 
marked.  Until  a  few  weeks  before  examination  the  voice  had 
been  quite  good,  and  even  afterwards  it  was  only  intermittently 
interfered  with.  These  attacks  of  aplionia,  however,  were  relieved 
by  coughing,  and  on  such  occasions  the  tumour  was  driven  up  into 
the  pharynx.  Deglutition  was  never  affected. 
^  The  oricrinal  was  not  accessible. 


1889.]  FATTY    TUMOURS   OF   THE   LARYNX.  705 

On  laryngoscopic  examination,  the  whole  of  the  larynx,  except 
the  riglit  margin  of  the  epiglottis  and  the  right  ary-epigiottic  fold, 
was  covered  by  a  tumour.  The  appearances,  however,  varied  from 
time  to  time,  and  after  great  difficulty  it  was  found  that  there  was 
a  growth  attached  to  the  left  margin  of  the  epiglottis,  the  corre- 
sponding pharyngo-epiglottic  fold,  the  lateral  wall  of  the  epiglottis, 
and  the  left  ary-epiglottic  fold  by  a  broad  pedicle.  The  tumour 
was  divided  into  finger-like  processes,  and  thus  the  variations  in 
the  laryngoscopic  appearances  were  accounted  for.  The  tumour 
was  eventually  removed  in  several  sittings  by  means  of  tlie 
galvano-caustic  snare,  and  proved  to  be  a  lipoma,  as  was  at  first 
conjectured  on  account  of  its  light  colour,  lobulated  appearance, 
and  soft  consistence. 

I  shall  now  briefly  recount  my  own  cases. 

(1.)  M.  W.  was  brought  to  me  by  Dr  Carmichael  on  the  23rd 
July  1887.  The  history  of  the  case  was  as  follows: — About  six 
months  ago  the  patient  felt  that  occasionally  in  breathing  he  made 
a  peculiar  noise,  but  this  occurred  only  for  two  or  three  minutes 
once  or  twice  a  day.  Eventually  this  symptom  became  trouble- 
some when  the  patient  lay  down,  and  finally  he  began  to  experi- 
ence difficulty  in  swallowing.  Tliere  was  no  pain,  but  deglutition 
required  a  distinct  effort,  and  was  accompanied  by  a  sound  audible 
to  those  in  the  neighbourhood. 

On  examining  the  throat  a  pale  pink  rounded  tumour  was  seen 
behind  the  tongue.  Examination  with  the  laryngoscope  and 
probe  showed  that  it  was  attached  to  the  epiglottis,  and  about  the 
size  of  a  pigeon's  egg.  As  my  electric  cautery  was  not  ready  for 
use  at  the  time  of  the  patient's  first  visit  the  wire  of  Jarvis's  snare 
with  a  bent  shaft  was  passed  over  the  tumour  and  tightened.  To 
make  a  long  story  short,  it  was  found  that  the  wire  could  not  be 
made  to  penetrate  the  growth,  and  the  part  seized  had  eventually 
to  be  cut  off  with  bent  scissors.  This  portion  comprised  about  a 
half  of  the  tumour.  The  remainder  was  easily  removed  by  means 
of  the  galvano-caustic  snare  adjusted  by  the  aid  of  the  laryngo- 
scope. The  first  portion  of  the  growth  removed  was  handed  over 
to  my  friend  Dr  Alex.  Bruce,  who  described  it  as  a  fibro-lipoma. 
The  other  half  I  now  show  you.  The  stump  which  was  left  had 
a  broad  attachment  to  the  right  valleculae  and  adjacent  part  of  the 
dorsum  linguae.  At  first  the  sloughing  resulting  from  the  electric 
cautery  produced  foetor  of  the  breath  and  a  bad  taste  in  the  mouth. 
These  symptoms  soon  yielded  to  the  use  of  a  boracic  acid  gargle. 
On  the  26th  December  1887  the  condition  of  parts  was  as  follows: 
"  Only  a  rounded  fulness  filling  up  right  vallecula  and  evidently 
attached  to  the  epiglottis  and  adjacent  part  of  the  tongue."  On 
the  3rd  December  1888  Dr  Carmichael  again  brought  the  patient 
to  me,  and  the  tumour  had  not  only  recurred,  but  readied  a  size 
equal  to  that  when  it  was  first  examined.  -  To  this  recurrence  I 
attach  little  importance  from  the  point  of  view  of  ultimate  prog- 

EDIN'BDRGH    MKD.   JOURX.,    VOL.  XXXIV. — NO.    VIII.  4  U 


706  DR   p.   M'BIUDE'S   clinical   notes   on  [FEB. 

nosis.  At  the  same  time,  it  is  evident  that  a  temleiicy  to  reap- 
pearance will  exist  so  long  as  any  part  of  the  tumour  is  left,  and 
it  will  be  no  easy  task,  situated  as  it  is,  to  extirpate  the  growth 
together  with  its  capsule  by  endo- laryngeal  operation.  From  a 
strictly  anatomical  point  of  view  it  may  be  contended  that  this 
was  not  "  a  fatty  tumour  of  the  larynx."  If  it  be  preferred  to  call 
it  "  a  fatty  tumour  in  the  larynx,"  this  in  no  way  detracts  from  the 
interest  of  the  case. 

My  second  case  of  laryngeal  lipoma  is  but  of  recent  date. 

P.  B,,  cet.  71,  porter,  applied  for  treatment  at  the  Koyal  Infir- 
mary on  the  16th  November  1888,  giving  the  following  history: — 
Some  five  or  six  months  ago  the  patient  felt  a  lump  in  his  throat, 
and  though  aware  of  its  presence  did  not  find  it  obstruct  the 
breathing,  cause  pain,  or  interfere  with  swallowing.  It  gradually 
enlarged,  causing,  last  September,  a  thickness  of  speech  and  ob- 
structing the  breathing  when  the  patient  lay  on  his  left  side. 
Latterly  difficulty  in  swallowing  has  been  experienced,  but  there 
has  been  no  pain  at  any  time.     Sleep  has  never  been  disturbed. 

On  laryngoscopic  examination,  a  pale  pink  mass  was  seen  over- 
lying the  left  arytenoid  cartilage.  On  touching  this  with  a  probe 
a  cough  resulted,  which  shot  the  tumour  up  to  a  level  with  the 
dorsum  of  the  tongue.  The  growth  was  eventually  seized  with  a 
vulsellum ;  the  snare  of  the  electric  cautery  was  then  passed  over 
it  and  pressed  well  down,  tightened,  and  the  tumour  removed. 
The  latter  was  fully  as  large  as  a  bantam's  egg.  A  fragment 
removed  was  examined  by  Dr  Martin  and  found  to  consist  of  fatty 
tissue.  I  now  show  you  the  lipoma  in  question,  and  it  will  be  at 
once  noticed  that  it  has  also  a  distinct  capsule.  After  removal  it 
was  seen  that  the  pedicle  was  narrow,  and  had  been  attached  to 
the  outer  part  of  the  right  pyriform  sinus.  The  patient  was  kindly 
given  a  bed  for  a  day  or  two  by  Professor  Annandale,  because  I 
feared  that  laryngitis  might  possibly  result  from  the  effects  of  the 
electric  cautery.  No  such  untoward  result,  however,  supervened, 
and  a  week  after  the  operation  only  a  white  eschar  was  visible  on 
the  outer  and  anterior  part  of  the  sinus  pyriformis.  From  the 
very  few  cases  so  far  published  it  is  impossible  to  generalize  as  to 
the  diagnosis  and  prognosis  of  fatty  tumours  of  the  larynx.  We 
may,  however,  say  that  tliey  are  characterized — (1),  by  their  light 
pink  colour ;  (2),  the  disproportion  between  their  size  and  the 
symptoms  they  produce ;  and  from  my  first  case  we  are  also 
entitled  to  conclude  that  unless  the  removal  be  complete  rapid 
recurrence  may  take  place. 

Since  writing  the  above  I  have  again  operated  on  my  first  case, 
in  which,  as  will  be  remembered,  recurrence  took  place.  The 
tumour  was  seized  with  a  strong  and  heavy  pair  of  catch  forceps. 
Over  these  the  galvano-caustic  snare  was  slipped,  and  tlie  growth 
which  I  now  show  you  removed.  As  will  be  observed,  it  has  the 
appearance  of  having  been  enucleated  rather  than  cut  off.     On 


1889.]  FATTY   TUMOURS   OF   THE   LAKYNX.  707 

examining  with  the  laryngoscope  after  the  operation,  from  which 
virtually  no  bleeding  resulted,  there  was  seen  to  be  an  excavation 
corresponding  to  the  point  of  attachment.  It  was  further  noted 
that  the  right  margin  of  the  epiglottis  was  somewhat  excavated, 
a  condition  probably  due  to  the  pressure  of  the  somewhat  pendu- 
lous tumour,  which,  although  attached  by  a  broad  base,  tended  to 
hang  over  into  the  laryngeal  cavity. 

This  last  operation  seems  to  indicate  the  advisability  of  seizing 
not  only  the  capsule  of  the  fatty  tumour,  but  also  the  adipose 
tissue,  so  that  the  latter  may  be  drawn  from  its  bed  and  enucleated 
as  completely  as  possible.  I  may  mention  that  when  the  patient 
was  last  examined  cicatrization  was  not  completed,  but  that  no 
reaction  of  any  note  had  followed  the  removal  of  the  growth. 


IV.  — THE    RELATIONSHIP    BETWEEN    NEURALGIA    AND 
ABORTION:  A  CLINICO-SPECULATIVE  NOTE. 

By  A.  D.  Leith  Napier,  M.D.,  M.K.C.P.  Lond.,  F.R.S.E.,  London. 

(Read  before  the  -Edinburgh  Obstetrical  Society,  12th  December  1888.) 

Keflex  neural  disturbances  is  confessedly  a  difficult  subject  to 
handle  judiciously.  The  term  "  reflex  causes,"  like  our  familiar 
and  much-abused  friends  "dyspepsia"  and  "febricula,"  is  in  great 
measure  simply  a  wide  and  unexplored  scientific  desert,  in  which 
the  barren  sands  of  speculations,  uncertain  and  indefinite,  are 
immeasurably  more  plentiful  than  the  grateful  and  refreshing 
wells  of  sparkling  precision,  or  the  comforting  oases  of  confident 
opinion.  How  to  clearly  understand  reflex  neuroses,  how  to 
estimate  their  force  and  import,  is  still  an  unsettled  problem  of 
our  modern  medicine.  If  we  as  obstetricians  accept,  even  in  a 
restricted  sense,  the  dictum  of  Marshall  Hall,  "  The  whole  question 
of  abortion  and  parturition,  and,  in  a  word,  of  Obstetrics  as  a 
science,  is  one  of  the  true  spinal  system,"  ^  surely  it  behoves  us  to 
devote  renewed  attention  to  so  important  a  theme.  In  a  former 
communication^  to  this  Society  I  touched  upon  reflex  paralysis 
in  connexion  with  puerperal  albuminuria;  in  the  subsequent 
valuable  discussion^  doubts  were  suggested  by  one  or  more  of  the 
speakers  with  reference  to  the  risks  I  encountered  when  I  ven- 
tured on  "  the  dangerous  ground "  of  reflex  paralysis.  Other 
speakers,  notably  Surgeon-major  Arnott,  who  spoke  with  reference 
to  practice  in  India,  referred  to  several  cases  of  convulsions,  which 
seemed  solely  due  to  mere  irritation  of  the  nervous  system.  The 
purport  of  the  present  paper  is  to  deal  only  with  that  form  of 
neurotic  affection  which  is  called  neuralgia. 

Many  years  ago  it  was  shown  by  Tyler  Smith  that  irritation  of 

^  Diseases  and  Derangements  of  the  Nervous  System. 

2  Transactions,  vol.  ix.  p.  122.  ^  J^id.^  p.  191  et  seq. 


708  DIl    A.    D.    LEITII    NAPIEIi    ON.  THE  [I'EB. 

the  excitor  nerves  and  of  the  spinal  centres  formed  the  two 
classes:  oxcentric  and  centric  causes  of  abortion.  He  thought  that 
irritation  of  the  extremities  of  the  excitor  nerves,  as,  for  example, 
irritation  of  tiie  mammary  nerves  (what  he  referred  to  as  the 
"  synergic  relations  between  the  mammae  and  the  uterus"),  and 
which  he  seemed  to  regard  as  wholly  peripheral,  was  due  to  some 
peculiar  and  direct  sympathy.  He  remarked  "  that  gastric  irrita- 
tion had  no  eifect  in  producing  abortion,"  nor  was  "  the  most 
extensive  lung  disease  accountable,"  although  "  the  synergies 
between  the  lungs  and  uterus  were  remarkable."  He  admitted 
that  irritation  of  the  trifacial  was  an  occasional  cause,  and  tliat 
sometimes  when  no  other  explanation  than  the  appearance  of  the 
wisdom  teeth  was  tlie  local  determinant.  Vesical  irritation  from 
calculi  or  chronic  inflammation  was  also  mentioned.  Jiectal  nerve 
irritation  is  "  a  common  cause  of  abortion,"  according  to  the  same 
writer ;  as  also  is  vaginal  nerve  and  ovarian  nerve  irritation.  I 
am  not  disposed  to  accept  the  entire  truth  of  these  observations ; 
yet  there  are  no  grounds  for  disputing  Smith's  influence  on  the 
subject  as  being  distinctly  helpful  to  those  who  have  read  his 
unquestionably  meritorious  and  original  ideas.  He  further  states, 
"  Irritation  of  the  uterine  nerves  is  beyond  doubt  the  most 
important  of  all  the  causes  of  abortion  ;  and  all  these  causes, 
whether  vaginal,  mammary,  vesical,  rectal,  facial,  or  uterine,  are 
purely  excito-motor  in  their  operation.  The  irritation  is  applied 
to  the  excitor  nerves,  and  reflected  through  the  spinal  marrow 
upon  the  motor  nerves  and  the  uterus."^ 

Modern  physiology  has  determined  certain  definite  groups  of 
nerves  with  distinct  functions,  which,  so  far  as  they  now  concern 
us,  may  be  mentioned : — (1.)  The  centrifugally  conducting  nerves, 
motor  nerves  for  the  smooth  muscles,  usually  involuntary,  with 
secretory,  trophic,  inhibitory,  and  vaso-dilator  nerves ;  (2.)  The 
centripetally  conducting  nerves  of  excito-motor  or  reflex  function. 
We  recognise  the  fact  that  the  nerves  entering  the  uterine  mucous 
membrane  are  connected  with  ganglia.  In  normal  gestation  there 
is  a  state  of  neurotic  impressibility  which  manifests  itself  at 
times  by  uncertainty  of  temper  or  sleeplessness  ;  by  perversions  of 
taste  or  smell ;  by  sickness,  by  amblyopia,  hemeralopia,  vertigo, 
syncope,  hyperassthesia,  or  attacks  of  neuralgia.  It  is,  of  course, 
debatable  whether  these  symptoms  are  due  to  reflex  causes  in 
consequence  of  the  changed  conditions  in  the  sexual  organs,  or  to 
the  leucocythsemia  of  pregnancy  and  the  consequent  results. 

While  there  is  generally  heightened  nervous  susceptibility,  there 
is  uterine  resistance  to  impressions,  or,  in  otlier  words,  increased 
nervous  inhibition  to  a  markedly  great  degree.  And  this  action, 
although  imperfectly  understood,  is  not  one  of  abeyance  of  excito- 
motor  action  and  interruption  to  the  conveyance  of  reflex  sensa- 
tions. The  theory  has  formerly  been  suggested  that  there  is 
^   On  Parturition,  p.  127,  etc. 


1889.]       RKLATIONSHir   BETWEEN   NEURALGIA   AND   ABORTION.  709 

"  an  independence  and  seclusion  of  the  nervi-motor  apparatus  of 
ovi-expulsion  until  the  appearance  of  the  exciting  causes  of  labour." 
While  we  admit  the  existence  of  distinct  centres  for  uterine  action, 
it  is  difficult  to  follow  a  theory  which  postulates  that  the  presence 
of  an  embryo  of  varying  size  and  relation  to  the  uterus  can  pro- 
duce a  local  blocking  of  reflex  impressions.  During  and  imme- 
diately after  parturition  the  spinal  centres  distinctly  control  the 
uterus,  yet  it  is  argued  that  "  during  pregnancy  no  reflex  action 
sufficient  to  cause  abortion  will  follow  immediately  upon  the 
application  of  the  ordinary  stimuli  of  excito-motor  action."  Now 
all  through  pregnancy,  very  markedly  during  the  latter  months, 
there  are  very  distinct  uterine  contractions  due  to  reflex  impres- 
sions ;  but  it  is  contended  that  "  it  is  necessary  that  the  nervous 
arcs  in  relation  with  the  uterus  must  be  continuously  irritated  for 
a  considerable  time  ere  reflex  action  occurs."  Admitting  that 
time  is  after  all  only  a  relative  term,  we  may  broadly  deny  the 
necessity  for  a  prolonged  irritation.  Emotions,  as  anger,  fear,  joy, 
etc.,  which  have  lasted  for  only  a  very  short  time,  are  clinically 
admitted  causes  of  abortion. 

It  may  best  serve  our  purpose  to  leave  for  the  present  the 
theoretical,  and  regard  certain  practical  and  clinical  facts.  Let  us 
recall  the  nervous  sujiply  of  the  uterus,  and  we  will  note  that  in 
continuance  with  and  from  the  great  splanchnic  we  have  the  aortic 
plexus,  which  divides  into  branches,  giving  rise  to  the  inferior 
hypogastric,  from  which  we  have  uterine  and  vaginal  branches ; 
and  the  aortic  plexus  terminating  in  the  hypogastric,  which 
originates  the  uterine  and  ovarian  plexuses.  The  hypogastric  is 
also  in  close  connexion  with  four  lumbar  ganglia  ;  and  also  in 
descent  from  the  aortic  plexus  we  have  directly  the  inferior 
mesenteries ;  so  that  it  is  easy  to  realize  how  many  and  important 
direct  results  may  be  due  to  disturbance  of  the  reflex  nerve 
supply. 

Neuralgia  of  cranial  and  spinal  nerves  is  very  often  associated 
with  abortion.  The  trifacial,  the  occipital,  the  brachial,  the  inter- 
costals,  the  sciatic,  and  the  pneumogastric  are  not  uncommonly 
affected. 

One  of  my  patients,  who  had  aborted  very  frequently,  before 
abortion  had  always  a  sharp  neuralgic  attack,  principally  affect- 
ing the  lachrymal  and  frontal  branches  of  the  fifth,  and 
running  down  the  cervical  plexus  to  about  the  middle  of  the 
neck.  She  had  in  addition  considerable  gastric  pain,  with 
a  tendency  to  flatulent  eructations.  In  this  case  the  neuralgia 
of  the  head  and  neck  invariably  preceded  uterine  action, 
and  at  no  other  times  was  this  lady  a  sufferer  from  neuralgia. 
Another  patient,  who  was  never  previously  neuralgic,  was  during 
the  sixth  month  of  her  first  pregnancy  attacked  with  severe 
gastralgia  with  nausea,  but  had  no  vomiting.  Foetal  movements 
became  feeble,  very  acute  neuralgia  of  one  side  of  the  face  and  neck 


710  DIl   A.    D.   LEITII   NAPIER   ON   THE  [FEB. 

supervened,  and  seven  days  from  the  onset  of  the  painful  symptoms 
she  was  prematurely  delivered  of  a  dead  child.  Another  case  had 
neuralgia  confined  to  the  intercostals  and  brachial  of  one  side  in 
two  successive  pregnancies ;  abortion  took  place  at  three  months 
in  the  first,  and  was  averted  in  the  second.  A  fourth  lady  had 
acute  neuralgia  of  the  face  and  down  one  arm,  with  distinct  uterine 
contractions  resulting,  at  each  period  for  the  first  six  months  of  her 
first  pregnancy.  I  might  give  many  other  cases,  but  will  rather 
state  my  experience  aphoristically. 

(1.)  Neuralgia  and  abortion  are  frequently  associated. 

(2.)  In  certain  cases  of  "  habitual  abortion,"  neuralgia  invariably 
manifests  itself  as  the  first  symptom,  attacking  cranial  or  spinal 
nerves  remote  from  the  uterus. 

(3.)  If  treatment  relieves  the  pain  there  is  a  strong  probability 
that  uterine  disturbance  will  not  commence,  or,  if  already  there  have 
been  contractions,  these  will  cease. 

(4.)  Neuralgia,  while  perhaps  most  common  in  the  rheumatic, 
occurs  in  different  types  of  patients:  in  the  anaemic,  dyspeptic, 
or  mal-nourished ;  or  in  the  overfed,  indolent,  and  plethoric. 

(5.)  Foetal  death  is  sometimes  the  evident  cause ;  sometimes 
evidently  results  from  the  reflex  irritation  associated  with  the 
neuralgic  pain. 

(6.)  Acute  neuralgias  occurring  in  pregnancy  may  not  in  any  way 
interrupt  healthy  gestation. 

(7.)  When  severe  facial,  cervical,  or  other  neuralgia  yields  to 
treatment,  even  although  the  embryo  is  dead,  uterine  contractions 
and  emptying  will  not  occur  for  days,  perhaps  weeks. 

(8.)  The  trifacial,  occipital,  and  cervical  nerves  are  most  com- 
monly affected ;  but  brachial,  intercostal,  lumbar,  and  sciatic 
neuralgias  are  also  met  with. 

(9.)  Acute  gastric  irritation  is  associated  with  neuralgia  and 
abortion.  Pregnancy  sickness,  although  very  severe,  but  seldom 
causes  miscarriage ;  but  gastrodynia,  which  is  sometimes  accom- 
panied by  salivation  and  a  constant  feeling  of  nausea  and  depres- 
sion, not  infrequently  precedes  acute  neuralgia,  which  eventually 
causes  uterine  irritation,  and  ends  in  abortion. 

The  neuralgias  of  the  sciatic  may  be  rheumatic  or  due  to  pressure 
or  other  purely  local  causes,  and  the  latter  will  specially  apply  to 
rectal  and  vesical  neuralgia.  Ovarian  neuralgia  is  in  my  experi- 
ence a  very  common  condition  in  aborting  women,  and  I  believe 
accounts  for  many  unexplained  cases ;  yet  we  can  hardly  separate 
ovarian  from  uterine  irritation  as  distinct  conditions  during  gesta- 
tion. Some  cases,  indeed,  admit  of  easy  discrimination.  One 
patient  who  threatened  to  abort  at  the  second,  third,  and  fourth 
months,  was  on  each  occasion  treated  by  bromides,  and  a  blister 
applied  over  the  left  ovarian  region,  which  was  markedly  tender, 
and  she  carried  her  child  to  term.  She  had  previously  miscarried 
twice  with  similar  symptoms.     It  has,  however,  been  said  that 


1889.]       RELATIONSHIP   BETWP:EN   NEURALGIA   AND   ABORTION.  711 

"  physical  irritation  of  excitor  surfaces  short  of  pain  or  sensation 
may  produce  the  entire  phenomena  of  abortion."  Tliis  is  possibly 
true,  but  not  very  probable.  As  a  supplementary  observation,  I 
would  add  that  painful  sensations  remote  from  the  uterus  not  in- 
frequently originate  abortion. 

I  have  said  nothing  of  neuralgia  from  dental  caries  ;  for  although 
dental  caries  is  so  common  in  pregnancy,  and  although  neuralgia 
very  frequently  results,  I  have  never  known  abortion  follow  this 
form  of  neuralgia.  Toothache  in  pregnancy  should  be  treated  on 
general  principles.  I  have  never  seen  ill  effects  follow  tooth 
extraction  in  pregnancy.  I  have  always  advised  the  exliibition  of 
nitrous  oxide  or  chloroform  for  such  operations  ;  or  else,  failing  the 
suitability  of  anaesthesia,  have  ordered  applications  of  local 
sedatives,  as  camphor  and  chloral,  or  chloroform,  to  be  used 
as  temporary  measures  until  after  parturition. 

The  fact  is,  that  neuralgias  due  to  peripheral  irritation,  sucli  as  a 
decayed  tooth,  or  bladder  concretion,  or  rectal  hsemorrhoids  or 
growths,  seem  to  be  much  less  important  than  neuralgias  associated 
with  general  constitutional  states  which  have  no  available  local 
explanation.  The  shocks  of  grave  operations,  e.g.,  ovariotomy  and 
herniotomy,  etc.,  have  been  undergone  during  pregnancy  without 
the  least  indication  of  uterine  disturbance. 

In  neuralgia  which  precedes  abortion  we  have  a  certain 
periodicity,  a  recurrence  marked  by  such  regularity  in  some  cases 
that  there  seems  to  be  a  suggested  special  or  peculiar  cause.  I  do  . 
not  recollect  any  connexion  with  distinct  or  even  slight  ague ;  but 
although  there  are  no  clinical  symptoms  of  malaria  further  than 
the  periodicity,  we  have  to  remember  that  we  have  not  only  a  con- 
dition of  hydrsemia,  but,  according  to  Virchow,  a  "  physiological 
leucocythsemia  of  the  blood,"  and  this  in  connexion  with  splenic 
enlargement,  more  or  less  permanent,  in  normal  gestation.  We 
have  flushings,  sweats,  and  chills ;  we  have  temporary  albuminuria, 
temporary  glycosuria — all  as,  by  no  means  rare,  manifestations 
of  puerpery. 

But  there  must  be,  there  is,  a  distinctly  different  pathological 
consideration  forced  upon  us, — "Why  do  these  conditions  cause  no 
interference  with  some  cases  and  prove  very  prejudicial  in  others  ? 
Are  the  theories  of  reflex  action  or  of  blood  deterioration  the  more 
important  ?  Are  there  no  other  possible  explanations  ?  Is  it  per- 
missible to  suggest  that,  as  in  certain  organic  neuroses  causing  loss 
of  speech,  sight,  taste,  smell,  and  locomotion,  and  as  in  some  of 
these,  in  which  only  certain  limited  areas  of  cerebral  or  spinal 
surface  are  affected,  we  have  only  very  partial  irritations  or 
paralysis,  there  may  be,  in  like  manner,  as  a  consequence  of  the 
general  perversion  of  pregnancy,  actual  limited  organic  paralysis, 
as  well  as  increased  excito-motor  sensibility  ?  Push  this  argument 
a  step  further.  As  we  have  increased  body  weight  (quite  beyond 
the    uterine    burden),  enlargement  of  heart,  bloodvessels,  liver, 


712  DR   A.    D.    LEITH   NAI'IKR   ON   THE  [FKB. 

f^lands,  kidneys,  etc.,  why  deny  the  possible  production  of  increased 
nniltiplication  and  eidargenient  of  neuroglia  and  nervous  tissue 
generally  ?  As  we  have  traced  tiie  uterine  nerve  supply  to  the 
splanchnic,  so  might  we  proceed  upwards  through  the  whole  chain 
of  sympathetic  ganglia  till  we  reached  the  upper  cervical  ganglia 
with  its  internal  brain  and  spinal  connexions.  And  if,  in  conse- 
quence of  an  undue  accumulation  of  neuroglia  cells,  possibly  from 
an  exaggeration  of  the  normal  blood  of  pregnancy,  or  again  from 
the  fibroid  changes  of  rheumatism,  or  from  the  sometimes  exceed- 
ingly obscure  lesions  of  neural  syphilis,  we  had  an  interruption  to 
the  perfect  conveyance  of  nervous  impressions,  and  probably  a  con- 
dition of  "  blocked  nerve  impulses,"  it  would  not  be  difficult  to 
realize  that  should  any  untoward  circumstance  arise,  irregular 
reflex  disturbances  would  be  apt  to  occur. 

The  deduction  therefore  is,  that  there  are  two  sets  of  nerve 
affections  in  pregnancy — (1),  those  of  simple  localized  peripheral 
origin,  as  neuralgia  from  dental  caries,  from  vesical,  rectal,  or 
pelvic  pressure,  which  seldom  go  on  to  cause  uterine  neuralgia  of 
such  degree  as  will  end  in  contractions  sufficient  to  cause  pre- 
mature expulsion  of  the  embryo ;  and  (2),  neuroses,  which  owe 
their  origin  to  general  conditions  of  constitutional  disturbance,  and 
which  may  manifest  themselves  by  appearing  as  acute  neuralgia 
of  cranial  or  spinal  nerves. 

In  the  latter  class  the  inhibitory  action  will  sooner  or  later  be 
gravely  affected,  and  the  normal  excito- motor  conditions  will 
speedily  involve  the  organ  upon  which  physiological  action  has 
exercised  its  paramount  influence, — that  is  to  say,  a  patient,  suffer- 
ing, for  example,  from  chronic  rheumatism,  will  be  apt  to  abort 
not  only  from  chronic  rheumatic  endometritis,  but  from  the  central 
neural  disturbance  due  to  the  blood  deterioration.  Neuralgia 
occurring  in  such  a  case  may  be  facial  or  intercostal,  but  speedily 
becomes  uterine,  not  from  peripheral,  but  from  central  causes  of 
irritation.  A  few  hours  after  the  commencement  of  an  acute 
rheumatic  neuralgia  in  the  head  and  neck,  sharp  ovarian  and 
uterine  irritation  is  experienced ;  contractions,  at  first  spasmodic, 
and  then  regular,  sharp,  and  in  muscular  waves,  accompanied  by 
hflemorrhagic  effusions,  may  very  shortly  terminate  the  pregnancy. 

I  have  found  that  the  successful  control  of  neuralgia  in  preg- 
nancy demands  attention  to  one  or  two  points.  If  the  patient  is 
anaemic,  quinine  given  alone  in  ten-grain  doses  twice  daily,  or,  still 
better,  with  a  grain  of  opium  with  each  dose,  is  best  as  an 
immediate  sedative,  and  free  doses  of  arsenical  solution  are  most 
nseful  as  inter-attack  treatment.  But  when  the  patient  is 
plethoric,  especially  if  there  is  a  gouty  or  rheumatic  tendency, 
chloride  of  ammonium,  ten  to  fifteen  grains,  every  two,  three,  or 
four  hours,  with  bromides  of  ammonium  or  sodium,  opium,  and 
aconite,  or  with  veratrum,  will  answer  best.  Viburnum  pruni- 
folium  is  of  the  greatest  value  in  some  cases,  and  certainly  ought 


1889.]       RELATIONSHIP    BETWEEN    NEUKALGIA  AND   ABOUTION.  713 

to  be  given  as  soon  as  the  uterine  pains  are  felt.  The  Liq.  Caulo- 
phyllum  et  Pulsatillse  Co,  promises  to  prove  valuable  as  a  uterine 
and  ovarian  sedative,  and  might  be  given  either  alone,  or  with 
viburnum  in  lessened  doses,  as  soon  as  acute  pain  has  subsided. 
Other  patients  will  do  well  with  antipyrin,  gr.  xv.,  every  two  or 
three  hours,  or  iodides  and  alkalies ;  and  for  some  I  conceive  a 
course  of  baths  at  Kissingen,  Kreuznach,  Ems,  or  Wiesbaden, 
will  do  more  good  than  any  drug.  But  we  must  act  promptly 
and  dose  liberally  during  the  acute  attack  of  neuralgia. 


v.— A  CASE  OF  RUPTURE  OF  THE  UTERUS. 

By  A.  A.  Matheson,  M.D. 

(Read  before  the  Edinburgh  Obstetrical  Society,  lith  November  1888.) 

Mr  President  and  Gentlemen, — It  has  seemed  to  me  that  the 
report  of  this  case  might  not  be  uninteresting,  inasmuch  as  the 
rupture  was  produced  mechanically,  and  the  patient  survived  the 
accident  for  nearly  a  fortnight.  There  are  also,  I  believe,  some 
other  points  of  interest  in  the  case. 

I  first  saw  the  patient  in  her  tenth  labour ;  the  previous  nine 
had  all  been  easy.  Pains  had  existed  for  nineteen  hours,  but  had 
been  very  feeble  and  irregular.  One  hour  before  my  arrival  the 
membranes  had  been  ruptured,  and  the  forceps  applied,  without, 
however,  bringing  about  any  advance  of  the  presenting  part.  On 
my  making  a  vaginal  examination,  a  brow  presentation  was  felt, 
the  occiput  lying  to  the  left  side  of  the  pelvis,  and  somewhat 
anteriorly.  Since  the  child  was  living,  and  the  membranes  had 
been  ruptured  but  one  hour  previously,  and  since  the  head  was 
not  engaged  in  the  brim,  it  was  considered  that  podalic  version 
was  the  best  treatment  to  be  adopted.  The  patient  having  been 
deeply  chloroformed,  no  difficulty  was  experienced  in  bringing 
down  a  foot  into  the  vagina,  the  body  of  the  child,  however,  did 
not  revolve,  the  head  remaining  at  the  brim  of  the  pelvis.  Gentle 
and  cautious  pressure  upwards  on  the  head  was  then  combined 
with  traction  upon  the  lower  extremity,  assistance  being  rendered 
at  the  same  time  by  abdominal  pressure,  and  version  was  com- 
pleted. Unfortunately  the  child  was  still-born,  some  delay  having 
occurred  in  the  birth  of  the  head,  which  was  above  the  average  size. 

It  was  noticed  that  as  the  head  escaped  from  the  vulva,  several 
large  blood-clots  immediately  followed.  Severe  haemorrhage  en- 
sued directly  afterwards,  for  which  friction  of  the  uterus  through 
the  abdominal  walls  was  employed,  ergotin  injected  subcutaneously, 
and  a  hot  water  intrauterine  injection  administered.  While  re- 
moving the  afterbirth  and  using  the  hot  water  (which  soon 
controlled  the  haemorrhage),  it  was  noticed  that  a  tear  existed  in 
the  uterine  wall  to  the  left  side,  and  somewhat  anteriorly.  The 
tear   extended   from   what   seemed   to   be    the   contraction   ring, 

EDINBURGH    MED.    JOURN.,    VOL.    XXXIV. — NO.   VIII.  4  X 


714  DIl   A.   A.   MATHESON'S   cask   of  [FEB. 

directly  upwards,  to  not  far  from  the  fundus.  From  the  tonic 
contraction  of  the  uterine  muscular  fibres,  the  edges  of  the  rent 
had  retracted,  leaving  a  wide  gap  into  which  a  large  part  of  the  hand 
easily  passed.  Though  the  rupture  involved  the  entire  thickness 
of  the  muscular  wall,  the  peritoneal  covering  was  felt  to  be  intact. 
Shortly  before  the  birth  of  the  child,  the  patient's  pulse  was 
fairly  good ;  after  the  haemorrhage  occurred,  and  for  two  hours 
afterwards,  no  pulse  whatever  could  be  perceived  at  the  wrist,  and 
the  patient  presented  the  typical  symptoms  of  profuse  haemorrhage. 
Stimulants  vi^ere  administered  by  the  mouth  and  subcutaneously, 
and  a  nutritive  enema  was  given. 

Twelve  hours  after  delivery  the  general  condition  of  the  patient 
had  much  improved.  The  pulse  was  130,  very  weak  and  com- 
pressible ;  temperature  normal.  She  complained  of  somewhat 
severe  pain  and  tenderness  in  the  left  iliac  region.  Extensive 
dulness  on  percussion,  believed  to  be  due  to  sub-peritoneal  haemor- 
rhage, existed  in  the  left  iliac  region,  and  to  a  less  degree  on  the 
right  side. 

The  subsequent  progress  of  the  case  was  as  follows : — The  pulse 
got  slightly  but  perceptibly  stronger  for  the  first  few  days,  but 
afterwards  remained  of  much  the  same  strength,  the  rate  varying 
from  108  to  126.  The  temperature  continued  normal,  except  on 
the  fourth  and  fifth  days,  when  it  rose  to  101°  and  101°"6  F. 
respectively.  The  pain  and  tenderness  on  the  left  side  diminished 
greatly  by  the  end  of  the  first  week,  and  were  almost  gone  shortly 
before  death.  The  dulness  in  the  right  iliac  region  disappeared  in 
a  few  days,  that  on  the  left  side  in  a  week.  On  the  fifth  day, 
patient  had  a  severe  attack  of  vomiting,  lasting  some  hours, 
during  which  nothing  would  remain  in  the  stomach;  these  attacks 
kept  recurring  at  intervals,  greatly  interfering  with  her  acquisition 
of  strength.  From  the  time  of  delivery  onwards,  some  slight 
difficulty  of  breathing  was  complained  of,  but  more  severe  attacks 
of  dyspnoea  occurred  at  intervals  for  a  few  days  before  death ;  in 
one  of  these  attacks  she  sank,  having  lived  thirteen  and  a  half 
days  after  parturition.  The  treatment  employed  during  the  puer- 
perium  was  perfect  rest,  and  the  administration  of  stimulants 
with  light  nutritious  food.  Vaginal  antiseptic  douches  were 
employed  a  few  times  on  account  of  some  slight  foetor  of  the 
lochia^  discharge. 

A  post-mortem  examination  was  performed  twenty-six  hours 
after  djath  by  Dr  Wm.  Keiller.  No  trace  of  peritonitis  was 
found,  with  the  exception  of  a  few  exceedingly  trifling  recent 
adhesions  of  the  great  omentum  to  the  side  of  the  abdominal 
cavity.  The  stomach  and  intestines  were  somewhat  distended. 
A  layer  of  blood  was  seen  under  the  peritoneum  which  covers  the 
posterior  abdominal  wall,  extending  from  the  brim  of  tlie  pelvis 
as  high  up  as  the  diaphragm.  Blood  was  also  seen  in  small 
amount  in  both  broad  ligaments,  in  the  utero-sacral  ligaments, 


1889.]  EUPTURE   OF   THE   UTERUS.  715 

behind  the  rectum,  and  beneath  the  portion  of  peritoneum  which 
passes  from  the  uterus  to  the  bladder.  The  left  broad  ligament 
was  quite  entire  but  somewhat  softened,  perhaps  from  post-mortem 
changes,  so  that  it  was  easily  ruptured  accidentally  by  the  finger, 
which  then  at  once  passed  directly  into  the  uterine  cavity.  The  tear 
in  the  uterine  muscular  wall  is  seen  in  the  specimen  I  now  show.  In 
connexion  with  the  examination  of  the  thoracic  organs,  an  ante- 
mortem  clot  was  found  in  the  pulmonary  artery,  extending  into  its 
small  branches.  I  believe  the  immediate  cause  of  death,  therefore,  to 
have  been  thrombosis  of  the  pulmonary  artery,  which  had  been 
induced  by  the  weak  and  exhausted  state  into  which  the  patient 
had  been  brought  by  the  post-partum  haemorrhage  and  the  severe 
attacks  of  vomiting  from  which  she  had  suffered.  In  this  way 
are  accounted  for  the  attacks  of  dyspnoea  occurring  before  death. 

The  above  case  appears  to  me  worthy  of  being  placed  on 
record  for  several  reasons.  In  the  first  place,  it  is  but  seldo.n  that 
cases  of  rupture  of  the  uterus  due  to  mechanical  injury  during 
obstetrical  operations  are  reported,  it  is  rather  that  variety  in 
which  rupture  occurs  spontaneously  in  a  labour  prolonged  from 
some  obstruction.  I  feel  certain  that  in  my  case  no  undue 
violence  was  employed;  and  I  have  therefore  been  led  to  the 
conclusion,  that  unless  the  foetus  is  very  freely  movable  within 
the  uterus,  podalic  version  is  much  more  dangerous  in  cases  in 
which  the  brow,  and  especially  the  face,  presents,  than  in  those 
where  we  have  the  vertex  presenting,  and  that  for  this  reason, — In 
vertex  cases  the  occiput  and  back  of  the  child  form  one  continuous 
curve — they  form,  as  it  were,  part  of  a  perfect  ovoid,  and  thus  the 
foetus  can  easily  be  made  to  revolve  on  its  axis.  In  face  and  brow 
presentations,  on  the  other  hand,  the  body  of  the  child  lies  so 
much  inclined  to  the  surface  of  the  uterus,  and  at  such  an  angle 
with  the  head,  that  any  attempt  to  cause  the  child  to  revolve  on 
its  transverse  axis  by  drawing  on  its  lower  extremities  will  tend, 
in  the  first  place,  to  bring  about  flexion  of  the  head  and  approxi- 
mation of  the  back  of  the  child  to  the  uterine  wall.  The  result 
will  be  that  the  occiput  acting  as  a  fulcrum,  marked  pressure  by 
it  in  an  outward  direction  will  be  exercised  on  the  uterine  wall, 
and  rupture  will  be  liable  to  occur. 

I  would  wish  also  to  draw  attention  to  the  retraction  of  the 
edges  of  the  tear  which  existed  after  delivery.  For  Lusk  states  that 
the  uterine  opening  in  such  cases  has  a  tendency  to  speedily  close. 

The  third  and  last  point  I  think  worthy  of  notice  is  that  from 
the  time  of  the  accident  until  death  occurred,  peritoneum  only 
intervened  between  the  peritoneal  and  uterine  cavities,  and  peri- 
tonitis was  not  set  up,  though  the  uterus  contained  septic  material. 
Would  it  not  then  be  of  advantage,  when  bringing  together  the 
edges  of  the  wound  made  in  the  uterine  wall  in  Csesarean  section, 
to  stitch  the  peritoneum  and  muscular  tissue  separately,  the 
peritoneum  having  been  first  stripped  or  dissected  off  to  some 


716  A  CASK  OF  RUPTURE  OF  THE  UTERUS.  [FEB. 

slight  extent  from  the  muscular  tissue  beneath.  By  this  method 
we  could  hope  for  a  rapid  union  of  the  edges  of  peritoneum,  and 
there  would  be  formed  a  barrier  between  the  uterine  and  peritoneal 
cavities,  if,  as  is  so  apt  to  happen,  the  wound  in  the  muscular 
wall  were  to  gape,  and  in  the  case  I  have  just  reported,  such  a 
condition  existed  for  nearly  a  fortnight  without  any  detriment  to 
the  patient. 


VI.— ON  THE  KELATIVE  WEIGHTS  OF  THE  PLACENTA  AND 

CHILD. 

By  G.  Owen  C.  Mackness,  B.A.  (Oxon.),  M.B.,  CM.,  late  Resident  Physician 
at  the  Royal  Maternity  Hospital,  and  at  the  Royal  Infirmarj',  Edinburgh. 

{Read  before  the  Edinburgh  Obstetrical  Society,  12th  December  1888.) 

The  idea  that  the  weight  of  the  placenta  at  full  term  is 
proportional  to  that  of  the  child  seems  to  be  widely  accepted. 
Many  of  our  text-books  agree  in  this  view,  while  others  make  no 
mention  at  all  of  their  relative  weights. 

For  instance,  Playfair  says,^ — "  The  size  (of  the  placenta)  varies 
greatly  in  different  cases,  and  it  is  usually  largest  when  the  child 
is  big,  but  not  necessarily  so." 

Parvin  writes,^ — "  Usually  the  weight  of  the  placenta  is  in  direct 
proportion  with  that  of  the  child." 

Charpentier  says,^ — "  The  weight  of  the  placenta  is,  however,  in 
proportion  to  the  bulk  of  the  child." 

While  resident  at  the  Edinburgh  Maternity  Hospital  I  was 
struck  with  the  number  of  exceptions  that  appeared  to  occur  to  the 
generally  accepted  rule,  and  I  consequently  started  a  series  of 
investigations,  the  results  of  which  are  embodied  in  this  paper. 

A  series  of  200  cases  were  taken  haphazard  from  the  records 
kept  at  our  Maternity  Hospital ;  as  far  as  possible  only  children 
born  at  full  term  were  taken,  while  dead-born  children  and  twins 
were  excluded  from  the  list.  In  the  Hospital  every  placenta  and 
child  is  weighed  immediately  after  delivery,  and  the  weights  along 
with  some  other  facts  are  recorded  in  a  register  kept  for  the  purpose. 
The  weights  of  these  200  children  were  added  together  and 
divided  by  200,  giving  thus  the  average  weight ;  the  corresponding 
placentae  were  treated  in  the  same  way.  Thus  there  was  obtained 
the  average  weight  of  the  children  with  the  corresponding  average 
weight  of  the  placentge,  viz.,  average  weight  of  child  7  lbs.  5*97  oz., 
with  an  average  weight  of  placenta  1  lb.  6  8  oz. 

Table  I.  was  then  constructed  as  follows : — These  200  children 

were  arranged  in  a  series  commencing  with  the  heaviest  child  and 

going  gradually  down  to  the  lightest  one.    Opposite  each  weight  of 

child  was  placed  the  weight  of  the  placenta  found  to  be  born  with 

*  Science  and  Practice  of  Midivifery,  vol.  i.  p.  104. 

^  Science  and  Art  of  Obstetrics,  p.  125. 

'  Traits  Pratique  des  Accouchement^,  vol.  i.  p.  185. 


1889.]        RELATIVE   WEIGHTS   OF  THE   PLACENTA   AND   CHILD.  717 

it.  In  some  cases  a  number  of  children  were  born  of  the  same 
weight  but  with  placentce  of  different  weights ;  the  average  weight 
of  these  placentse  was  then  taken,  e.g.,  four  children  were  born,  each 
weighing  6  lbs.  4  oz.,  while  the  placentae  weighed  respectively 
1  lb.  2  oz.  and  three  of  1  lb.  4  oz. — that  is  to  say,  an  average  weight  of 
placenta  of  1  lb.  3'5  oz.  Thus  the  average  weight  of  placenta  that 
was  born  with  each  weight  of  child  was  obtained.  The  last  column 
was  obtained  thus :  It  was  found  above  that  in  these  200  cases  the 
average  weight  of  the  children  was  7  lbs.  5'97  oz.,  and  the  average 
weight  of  the  placentae  1  lb.  6'8  oz. ;  then  by  a  simple  proportion 
sum,  if  a  child  of  7  lbs.  5-97  oz.  has  a  placenta  of  1  lb.  6'8  oz.,  what 
weight  of  placenta  should  any  given  weight  of  child  have  if  the 
placenta  and  the  child  are  proportional  in  weight.  The  results  so 
obtained  were  placed  in  the  fourth  column  opposite  the  weights  in 
the  third  column,  which  were  those  found  to  occur  in  actual 
practice.  As  a  still  further  test,  the  process  was  reversed  by 
placing  the  weights  of  the  placentae  in  a  descending  series,  and 
placing  opposite  each  given  weight  of  placenta  the  weights  of  the 
children  born  with  it.  The  fourth  column  in  this  case  was  formed 
in  a  similar  way,  substituting  the  weights  of  the  children  for  those 
of  the  placentae. 

If,  then,  the  law  that  the  weight  of  the  placenta  is  proportional 
to  the  weight  of  the  child  be  true,  the  third  and  fourth  columns 
should  coincide.  But  on  looking  over  the  table  this  will  be  found 
in  most  instances  not  to  be  the  case,  while  in  very  many  instances 
the  differences  are  very  striking ;  this  is  especially  evident  in  the 
second  part  of  the  table,  where  the  children's  weights  corresponding 
to  given  weights  of  placentae  are  placed.  Another  fact  which  at 
once  strikes  us  on  looking  over  this  table  is  that  with  any  given 
weight  of  placenta  children  of  most  varying  weights  are  found,  e.g., 
with  a  placenta  weighing  1  lb.  5  oz.,  fourteen  children  were  born 
with  weights  varying  from  6  lbs.  to  8  lbs.  15  oz. 

These  200  cases,  of  course,  extend  over  a  long  period  of  time, 
and  the  weights  were  taken  by  several  different  people,  who  might 
not  have  been  quite  accurate  in  their  observations,  consequently  I 
took  another  series  of  130  cases  whicli  were  all  delivered  during 
the  year  1887,  and  in  which  the  weights  were  all  taken  by  the 
same  person.  The  results  are  embodied  in  Table  II.,  which  is 
constructed  on  exactly  the  same  principle  as  the  former  one.  The 
results  in  this  case  are  similar  to  those  obtained  in  Table  I. 

Another  objection  that  might  be  raised  is  that  the  weight  of  the 
placenta  varies  with  the  amount  of  blood  which  it  contains,  this  of 
course  depending  on  the  time  at  which  the  cord  is  tied.  Since 
these  children  were  necessarily  delivered  by  a  number  of  different 
resident  physicians,  it  is  impossible  to  say  that  the  cord  was 
always  tied  at  the  same  time  after  delivery  in  each  case.  I  con- 
sequently took  another  series  of  62  cases  which  were  delivered 
during  the  time  that  I  was  myself  resident,  and  when  we  invariably 


718 


MR   G.    OWEN   C.   MACKNESS   ON   THE 


[FEB. 


tied  the  cord  immediately  after  the  birth  of  the  child.  These 
observations  are  to  be  found  in  Table  III.,  which  shows  exactly 
the  same  results  as  the  other  two. 

It  will,  I  know,  be  argued  that  in  compiling  these  tables  the 
very  small  and  very  large  placentae  and  children  should  have  been 
excluded  from  them.  I  do  not  think,  however,  that  this  is  the  case, 
for  what  I  wish  to  show  is  that  although  the  child  be  large  we 
need  not  on  that  account  expect  to  find  a  large  placenta,  and  vice 
versd.  By  excluding  those  cases  which  do  not  suit  our  purpose,  it 
is  of  course  easy  to  make  statistics  prove  anything ;  but  here  the 
cases  have  been  taken  just  as  they  came  in  the  records,  starting 
with  an  entirely  unbiassed  opinion,  and  quite  willing  to  be 
convinced  either  way  by  the  facts  as  they  were  found  to  exist. 

Since  these  investigations  were  commenced  there  have  been 
published  some  results  from  an  infinitely  larger  number  of  cases 
occurring  in  the  Dresden  Lying-in  Hospital.  These  state — "  An 
endeavour  was  made  to  show  the  relationship  of  the  size  and 
weight  of  the  placenta  to  the  child,  but  the  data  would  not  admit 
of  more  than  the  assertion  that  the  uterus  of  elderly  women,  from 
frequent  menstruation,  had  large  folds  and  elevations  of  the 
mucous  membrane  which  favoured  the  formation  of  a  large 
placenta.  The  uteri  of  multiparee  were  also  favourable  to  the 
formation  of  a  large  placenta,  in  consequence  of  the  preceding 
involutions,  which  offered  less  resistance  to  the  formation  of  a  large 
placenta."^  Of  the  truth  or  otherwise  of  these  assertions  I  am 
quite  unable  to  speak :  on  attempting  to  bring  the  relation  of  age 
and  parity  into  the  above  calculations,  the  results  were  found  to 
be  far  too  complex  to  be  satisfactorily  worked  out. 


TABLE  I. 

Average  Weiglit  of  Child  in  200  Cases  =  7  lbs.  5-97  oz. 
II  II  Placenta  m  =1  lb.    6*8  oz. 


Weight  of 
Child. 

Weight  of 
Placenta. 

Average 
Weight  of 
Placenta. 

Proportional 

Weight  that 

the  Placenta 

should  be. 

Weight  of 
Child. 

Weight  of 
Placenta. 

Average 
Weight  of 
Placenta. 

Proportional 
Weight  that 
the  Placenta 
should  be. 

lbs.    oz. 

lbs.   oz. 

lbs.    oz. 

lbs.     oz. 

lbs.    oz. 

lbs.  oz. 

lbs.    oz. 

lbs.     oz. 

9       8 

1      12 

1  12 

2  0 

1     13-3 

1    13-488 

8      10 

1      10 
1       7 
1       7 

1      7-75 

1    10-772 

9       6 

2       8 

2      8 

1     131 

1       7 

9       4 

1      14 

1     13-5 

1    12712 

8        9 

1      12 

1     12 

1    10-578 

1      13 

8       8 

1       14 

1      9-7 

1    10-384 

9       2 

2       0 

2      0 

1    12-324 

1       12 

9        1 

1        8 

1      8 

1    12-13 

1       12 

9       0 

2        1 

2      1 

1    11-936 

1       12 

8      15 

1        5 

1      5 

1     11-742 

1       12 

8      14 

1        4 

1      4 

1     11-548 

1       11 

8      13 

1      12 

1    12 

1     11-354 

1       10 

8      12 

1      13 
1      12 
1       12 
1        9 
1        8 
1        4 
1        0 

1      8-3 

1    1116 

1       10 
1       10 
1        9 
1        9 
1        6 
1        5 
1        4 

I 


Medical  Press,  Oct.  5tli,  1887,  p.  320. 


1889.]         RELATIVE   WEIGFITS   OF   THE   PLACENTA   AND   CHILD.  719 

TABLE  I. — continued. 


Weight  of 

Weight  of 

Average 
Weight  of 
Placenta. 

Proportional 

Weight  that    Weight  of 

Weight  of 

Average 
Weight  of 
Placenta. 

Proportional 
Weight  that 

ChUd. 

Placenta. 

the  Placenta 
should  be. 

Child. 

Placenta. 

the  Placenta 
should  be. 

lbs. 

oz. 

lbs.  oz. 

lbs.    oz. 

lbs.     oz. 

lbs.    oz. 

lbs.   oz. 

lbs.    oz. 

lbs.     oz. 

8 

7 

1      15 

1       7 

1    11 

1    10-19 

7       0 

1      12 
1      10 

1      6-7 

1      5-728 

8 

6 

1      12 
1      10 
1        8 
1        4 
1        3 

1      5-4 

1      9-996 

1      10 
1        8 
1        8 
1        8 
1       7 

8 

5 

1        4 

1      4 

1      9-802 

1       6 

8 

4 

1      12 
1      10 
1        9 
1        5 
1        4 

1      6-57 

1      9-608 

1       5 
1       5 
1        4 
1        4 
1        0 

1        4 

6      15 

2        4 

1    10-6 

1      5-534 

1        2 

1        8 

8 

2 

1        0 

1      0 

1      9-22 

1        4 

8 

1 

1        8 
1        8 

1      8 

1      9-026 

6      14 

1        7 
1        5 

1      4-4 

1      5-34 

8 

0 

1      10 
1        6 
1        4 

1      4-375 

1      8-832 

1        4 
1        3 
1        3 

1        4 

6      13 

1       10 

1      6-6 

1      5-146 

1        4 

1        8 

1        4 

1        8 

1        3 

1        5 

1        0 

1         2 

7 

14 

2        0 
1        6 
1        6 
1        3 

1      7-75 

1      8-44 

6      12 

1       12 
1       11 
1        5 

1        4 

1      4-4 

1      4-952 

7 

13 

1        9 

1      9 

1      8-25 

1        4 

7 

12 

1        9 
1        5 
1        4 
1        4 

1      5-5 

1      8-056 

1        2 
1        2 

1        0 
1        0 

7 

10 

1      10 
1        8 

1      7-6 

1      7-668 

6      11 

1       11 
1        0 

1      5-5 

1      4-758 

1        8 

6      10 

1        8 

1      6 

1      4-564 

1        6 

1       7 

1        6 

1       5 

7 

9 

1        4 

1      4 

1      7-474 

1        4 

7 

8 

1      14 
1      10 
1        8 
1       7 

1      6-9 

1      7-28 

6       9 

1        8 
1        4 
1        2 
1        1 

1      3-75 

1      4-37 

1       7 

6       8 

1        9 

1      4-6 

1      4-176 

1       7 

1        4 

1       5 

1        1 

1       4 

6        6 

1        9 

1      4-8 

1      3-788 

1       4 

1        5 

1       3 

1        4 

7 

7 

2        0 
1       7 

1      9 

1      7-086 

1        4 
1        2 

1        4 

6        5 

1        9 

1      3-3 

1      3-594 

7 

6 

1        8 
1        5 

1      5-6 

1      6-892 

1        1 
1        0 

1        4 

6       4 

1        4 

1      3-5 

1      3-4 

7 

5 

1        9 
1        2 

1      5-5 

1      6-698 

1        4 
1        4 

7 

4 

1       14 

1      6-625 

1      6-504 

1        2 

1        9 

6        3 

1       12 

1      6 

1      3-206 

1        8 

1        0 

1       7 

6       2 

0      15 

0    14-5 

1      3-012 

1       6 

0      14 

1        4 

6        1 

1       10 

1     10 

1      2-818 

1        3 

6       0 

1        5 

0    15-5 

1      2-624 

1        2 

0      10 

7 

3 

1       7 

1      7 

1      6-310 

5      14 

1        4 

1      4 

1      2-236 

7 

2 

1      15 
1      10 

1      6 

1      6-116 

5      13 

1        2 

1         2 

1      2 

1      2-042 

1        4 

5      12 

1         4 

1      4 

1       1-848 

1        4 

5      10 

1         8 

1      8 

1       1-46 

1        3 

5        8 

1       7 

1      2-75 

1       1-072 

1        0 

1        4 

7 

1 

1        3 
1        2 

1      1-6 

1      5-922 

1        4 
0      12 

_ 

1        0 

5       7 

1        1 

1      1 

1      0-878 

720 


MR   G.   OWEN    C.   MACKNESS   ON   THE 


[FEB. 


TABLE  1.— continued. 


Weight  of 
Cliild. 

Weight  of 
Placenta. 

Average 
Wciglit  of 
Pliiceuta. 

Proportional 
Weight  tliat 
the  i'laeeuta 
should  be. 

Weight 
Placenta. 

Weight  of 
ChUd. 

Average 

Weight  of 

Child. 

Proportional 

Weight  that 

the  Child 

should  be. 

lbs.    oz. 

lbs.   08. 

lbs.    oz. 

lbs.     oz. 

lbs.  oz. 

lbs. 

OS. 

lbs.        OB. 

lbs.     oz. 

5       6 

1      13 
1       2 

1      7-5 

1      0C»4 

1      9 

6 
6 

6 
6 

5       4 

1        0 
0      14 

0    15 

I      0-296 

1      8 

9 
8 

1 
12 

7      5-95 

7    12176 

5       0 

1        3 

1                 1 

1      2 

0    15-52 

8 

6 

4      12 

1                 1 

1        4 

1      4 

0    14744 

8 
8 

1 
1 

4       6 

1        6 

1      6 

0    13-58 

7 
7 

10 
10 

7 

8 

Weight 
Placenta. 

Weight  of 
ChUd 

Average 

Weight  of 

ChUd. 

Proportional 

Weight  tliat 

the  Child 

should  be. 

7 
7 
7 
7 
7 

6 
4 
0 
0 
0 

lbs.  oz. 

lbs.     oz. 

lbs.     oz. 

lbs.      oz. 

6 

15 

2      8 

9       6 

9      6 

12    14-96 

6 

13 

2      4 

6      15 

6    15 

11     10-264 

6 

13 

2      1 

9       0 

9      0 

10    10-762 

6 

10 

2      0 

9        8 
9        2 

8      7-75 

10      5-668 

6 
5 

9 
10 

7      14 

1      7 

8 

10 

7      7-643 

7      7-002 

7        7 

8 

10 

1     15 

8        7 
7        2 

7     12-5 

10      0-394 

8 
8 

10 

7 

1     14 

9        4 
8        8 
7        8 
7        4 

8      2 

9    11-22 

7 
7 
7 
7 

8 
8 
8 
7 

1     13 

9        4 
8      12 
6        6 

7    12-6 

9      6046 

7 
7 
7 

4 
3 

0 

I     12 

9        8 
9        8 
8      13 

8      4-73 

9      0-872 

6 
6 
5 

14 
10 
8 

8      12 

1      6 

8 

8 

7      7-2 

7      1-828 

8      12 

8 

6 

8        9 

8 

0 

8       8 

7 

14 

8       8 

7 

14 

8       8 

7 

10 

8        8 

7 

10 

8        6 

7 

4 

8        4 

7 

0 

7        0 

4 

6 

6      12 

1      5 

8 

15 

7      4-286 

6    12-654 

6        3 

8 

8 

1    11 

8        8 
6      12 
6      11 

7      5 

8    11-698 

8 
7 
7 

4 
12 

8 

1     10 

8      10 
8        8 
8        8 
8        8 
8        6 
8        4 
8        0 
7      10 
7        8 

7    11-285 

8      6-524 

7 
7 
7 
6 
6 
6 
6 
6 
6 

6 
0 
0 
14 
13 
12 
10 
6 
0 

7        2 

1      4 

8 

14 

7      1-718 

6      7-48 

7        0 

8 

12 

7        0 

8 

8 

6      13 

8 

6 

6        1 

8 

4 

1      9 

8      12 

7      9-18 

8      1-35 

8 

4 

8        8 

8 

0 

8       8 

8 

0 

8       4 

8 

0 

7      13 

8 

0 

7      12 

7 

12 

T        6 

7 

12 

7        4 

7 

9 

6        8 

7 

8 

1889.]         RELATIVE   WEIGHTS   OF   THE   PLACENTA   AND   CHILD.  721 

TABLE  I. — continued. 


Weight 

of 
Placenta. 

Weight  of 
Child. 

Average 

Weight  of 

Child. 

Proportional 

Weiglit  that 

the  Cliild 

should  be. 

Weight 

of 
Placenta. 

Weight  of 
ChUd. 

Average 

AVeightof 

ChUd. 

Proportional 

Weight  that 

the  Child 

should  be. 

lbs.  oz. 

lbs.       02. 

lbs.     oz. 

lbs.     oz. 

lbs.  oz. 

lbs.     oz. 

lbs.     oz. 

lbs.        02. 

1      4 

7        8 
7        7 
7        6 
7        4 
7        2 
7        2 
7        0 
7        0 
6      15 
6      14 
6      12 
6      12 
6      10 

1      2 

8        4 
7        5 
7        4 
7        1 
6      13 
6      12 
6      12 
6        9 
6        6 
6        4 
5      13 
5      13 
5        6 

6    10-3 

5    13132 

6        9 

1      1 

6        9 

5    154 

5      7-958 

6        8 

6        8 

6        6 

6        5 

6        6 

5        7 

6        4 

5        0 

6        4 

1      0 

8      12 

7      0 

5      2-748 

6        4 

8        2 

5      14 

8        0 

5      12 

7        2 

5        8 

7        1 

5        8 

7        0 

4      12 

6      12 

1      3 

8        6 
8        0 
7      14 
7        8 
7        4 

7      31 

6      2-306 

6      12 
6      11 
6        5 
6        3 
5        4 

7        2 

0    15 

6        2 

6      2 

4    18-61 

7        1 

0    14 

6        2 

5      11 

4      8-436 

6      14 

5        4 

6       14 

0    12 

5        8 

5      8 

3    14-088 

5        0 

0    10 

6        0 

6      0 

3      3  74 

TABLE  IL 

Average  Weiglit  of  Child  in  130  cases  born  during  part  of 


1887  =  7  lbs.  6-03  oz. 
=  1  lb.    6-52  oz. 


Weight  of 

Weight  of 

Average 
Weight  of 
Placenta- 

Proportional 
Weight  that 

Weight  of 

Weight  of 

Average 
Weight  of 
Placenta. 

Proportional 
Weight  that 

Child. 

Placenta. 

the  Placenta 
should  be. 

ChUd. 

Placenta, 

the  Placenta 
should  be. 

lbs.     02. 

lbs.    oz. 

lbs,    oz. 

lbs.    02. 

lbs.     02. 

lbs.     02. 

lbs.    oz. 

lbs.     02. 

11        0 

1        4 

1      4 

2      1-44- 

8        5 

1        8 

10       0 

1      10 

1    10 

1     14-4 

1        5 

9      13 

2       0 

2      0 

1     13-83 

8       4 

1      11 

1      8 

1      9-08 

9      10 

1      14 

1     14 

1     13-26 

1       7 

9       4 

2       0 

1     13 

1     12-12 

1        6 

1      10 

8        3 

2       3 

1     12 

1      8-89 

9       2 

1        8 

1      8 

1     11-74 

1        5 

9       0 

1      12 

1    12 

1     11-36 

8        1 

1        8 

1      8  . 

1      8-51 

1      12 

8       0 

1        9 

1      5-6 

1      8-32 

8      15 

1        8 

1      8  . 

1     11-17 

1        5 

8      13 

1      11 

1      7-6 

1     10-79 

1        3 

1        8 

7      15 

1        3 

1      1-5 

1      8-13 

1        4 

1        0 

8      12 

1        8 

1      8 

1     10-6 

7      14 

1        9 

1      9 

1      7-94 

8      11 

1      14 

1    12 

1    10-41 

7      13 

1        4 

1      4 

1      7-75 

1      10 

7      12 

1        8 

1      6-4 

1      7-56 

8      10 

1        5 

1        4 

1      4-5 

1     10-22 

1        8 
1        6 

8       8 

1       11 
1        8 

1      8-5 

1      9-84 

1        6 
1        4 

1        8 

7      11 

2        0 

1     11 

1      7-37 

1        7 

1        9 

8       6 

2        0 

2      0 

1      9-46 

1        8 

8       5 

1      12 
1        9 

1      8-5 

1      9-27 

7       9 

1        8 
1        8 

1      6 

1      6-99 

EDINBURaH   MED.    JOUBN.,   VOL.    XXXIV. — NO.   VIII. 


4  Y 


722 


MU   G.   OWEN   C.    MACKNESS   ON   THE 


[FEB. 


TABLE  II. — continued. 


Weight  of 
Child. 

Weight  of 
Placenta. 

Average 
Weiglit  of 
Plaeentiu 

Proportional 

Weiglit  that 

the  Placenta 

should  be. 

Weight  of 
Placenta. 

Weight  of 
Child. 

Average 

Weight  of 

ChUd. 

Proportional 

Weiglit  that 

the  Child 

should  be. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs. 

oz. 

lbs.    oz. 

lbs.    oz. 

7       9 

1       4 

1       4 

2        3 

8 

7 

3 
8 

7    13-5 

11      7-4 

7       8 

2        3 
1      14 
1        U 
1        8 
1        7 

1      7-36 

1      6-81 

2       0 

9 
9 
8 
7 
7 

13 
4 
6 

11 
3 

8     7-4 

10      7-68 

1      a 

1      14 

9 

10 

8     9-6 

9      13-2 

I        6 

8 

11 

1         4 

7 

8 

1        4 

1      12 

9 

0 

8      2 

9      1-72 

1        3 

9 

0 

1        2 

8 

5 

7       7 

1        9 
1        7 

1      (i-6 

1      6-61 

7 

7 

5 
0 

1        4 

1      11 

8 

13 

8      1-75 

8    12-48      : 

7       6 

1        8 
1        5 

1      6-5 

1      6-42 

8 
8 

8 

4 

1 

7       5 

1       12 

1      8 

1      (i-3 

6 

14 

i 

1        4 

1      10 

10 

0 

7    15-5 

8      8-24 

7       4 

1        « 
1        8 
1        6 
1        4 
1        4 

1      G 

1      (i-04 

9 
8 
7 
6 
6 

4 
11 
0 
8 
(> 

7       3 

2        0 
1        8 
1        2 
1        1 

1      6-75 

1      5-85 

1        9 

8 

8 

7 

7 

5 
0 
14 
11 

7    13-8 

8      3 

7       2 

1        6 

1      5 

1      5-64 

7 

7 

1        5 

1        8 

9 

2 

7      7-5 

7    1376 

1        4 

8 

15 

7       1 

1        8 
1        2 

1      5 

1      5-45 

8 
8 

13 
12 

7       0 

1       12 
1      10 
1        8 
1        8 
1        8 
1        7 
1        5 
1        4 
1        4 

1      7-3 

1      5-26 

8 
8 
8 
8 

7 
7 
7 
7 

7 

8 
8 
5 
1 

12 
12 
11 
9 
9 

6      14 

1      11 
1        8 
1        4 
1        0 

1      5-75 

1      4-88 

7 

7 

7 
7 

8 
8 
6 

4 

6      13 

1        0 

1      0 

1      4-69 

7 

4 

6      12 

1        7 
1        5 
1        4 

0      12 

1      3 

1      4-5 

7 
7 
7 
7 

3 
1 
0 
0 

6       8 

1      10 
1       7 

1      8-5 

1      3-74 

7 
6 

0 
14 

6       7 

1       4 

1      4  . 

1      3-55 

6 

6 

6       6 

1      10 
1        8 
1       5 

1      7-6 

1      3-36 

6 
5 

4 

2 
14 
8 

6       5 

1        4 

1      4 

1      3-17 

1       7 

8 

8 

7     6-7 

7      8-52 

6        4 

1        4 

1      4 

1      2-<)8 

8 

4 

6        3 

1        0 

1      0 

1      2-79 

7 

8 

6       2 

1        8 
1        4 

1      6 

1      2-6 

7 

7 

7 
0 

6       0 

1        6 
1        2 

1      1-5 

1      2-22 

6 
6 

12 
8 

1        0 

1        6 

8 

4 

7      3-2 

7      3-38 

1        0 

7 

12 

5      14 

1        8 
1        4 

1      6 

1       1-84 

7 
7 

12 
8 

5      13 

1        2 

1      2 

1      1-65 

7 

8 

5      11 

1        6 

1      6 

1      1-27 

7 

4 

5      10 

1        2 

1      2 

1      1-08 

7 

2 

5       8 

1        4 

1      4 

1      0-7 

6 

0 

5        5 

1        1 

1      1 

1      013 

5 

11 

5        4 

1        0 
0      12 

0    14 

0    15-94 

1       5 

8 
8 

10 
5 

7      8-4 

6    14-04 

5       0 

1        0 
0      14 

0    15 

0    1518 

8 
8 

3 

0 

4      14 

1        4 

1      4 

0    14-72 

7 

6 

1    *       8 

1        8 

1      8 

0    13-58 

7 

2 

1889.]        RELATIVE   WEIGHTS    OF   THE   PLACENTA   AND   CHILD.  723 

TABLE  11.— continued. 


Weight  of 
Placenta. 

Weight  of 
Child. 

Average 

Weight  of 

Child. 

Proportional 

Weight  that 

tlie  Child 

sliould  be. 

Weight  of 
Placenta. 

Weight  of 
Child. 

Average 

Weight  of 

ChUd. 

Proportional 

Weight  that 

the  ChUd 

should  be. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

1       5 

7       0 
6      12 
6       6 

1        4 

5      14 
5       8 
4      14 

1       4 

11        0 
8      13 

8      10 

7      2-9 

6      8-8 

1        3 

8        0 
7      15 
7       8 

7    13 

6      8-56 

7      13 

1        2 

7       8 

6     8-5 

5    14-82 

7      12 

7       3 

7       9 

7       1 

7       9 

6       0 

7       8 

5      13 

7       8 

5      10 

7       7 

1        1 

7       3 

6     4 

5      9-08 

7       5 

5        5 

7       4 

1        0 

7      15 

6     4-12 

5      3-84 

7       4 

6      14 

7        2 

6      13 

7       0 

6        3 

7       0 

6       0 

6      14 

6       0 

6      12 

5        4 

6       7 

5       0 

6       5 

0      14 

5       0 

5     0 

4      9-86 

6       4 

0      12 

6      12 

6      0 

8    14-88 

6       2 

5       4 

TABLE  III. 

Average  Weight  of  CMld  in  62  cases  born  during  Quarter  ending  31st  October 
1887  =  7  lbs.  3-45  oz. 

Average  Weight  of  Placenta  in  62  cases  born  during  Quarter  ending  31st 
October  1887  =  1  lb.  7-19  oz. 


Weight 

of 
Child. 

Weight  of 
Placenta. 

Average 
Weight  of 
Placenta. 

Proportional 

Weight  that 

the  Placenta 

sliould  be. 

Weight 
Child. 

Weight  of 
Placenta. 

Average 
Weight  of 
Placenta. 

Proportional 

Weiglit  that 

the  Placenta 

should  be. 

lbs.  oz. 

lbs.    oz. 

lbs.     oz. 

lbs.     oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

lbs.    oz. 

9    10 

1        7 

1       7 

1     14-8 

7      1 

1        7 

1       7  . 

1       6-6 

9      8 

2        0 

2       0 

1     14-4 

7      0 

1        9 

1       7-6 

1       6-4 

9      6 

1      14 

1     14 

1     13-8 

1        8 

9      4 

1      15 

1     15 

1     13-6 

1        6 

9      2 

1        9 

1       9 

1     13-2 

6    15 

1        2 

1       2 

1       6-2 

8    14 

1        7 

1       7 

1     12-4 

6    14 

1        8 

1       5 

1       6 

8    12 

1        7 

1       7 

1     12 

1        4 

8    10 

1       12 

1     11-3 

1     11-6 

1        3 

1       11 

6    13 

1        8 

1       8 

1       5-8 

1      11 

6    11 

1        6 

1        4 

1       5-4 

8      8 

2        2 
1      11 

1     14-5 

1     11-2 

1        4 
1        2 

8      4 

1        9 

1       7-5 

1     10-4 

6    10 

1        4 

1       4 

1       5-2 

1        6 

6      8 

1        9 

1       6-3 

1       4-8 

8      3 

1        8 

1       8 

1     10-2 

1        6 

8      2 

1        4 

1       4 

1      10 

1        4 

8      0 

1      12 

1      12 

1       9-6 

6      7 

1        7 

1       5-6 

1       4-6 

7     15 

1        8 

1       8 

1       9-4 

1        4 

7    14 

1        6 

1       6 

1       9-2 

1        3 

7    13 

2        0 

1     14 

1       9 

6      6 

1        7 

1       7 

1       4-4 

1      12 

6      3 

1        5 

1       2-5 

1       3-8 

7    12 

1        4 

1        4 

1       8-8 

1        0 

7     11 

1        9 

1       9 

1       8-6 

6      2 

1        3 

1       3 

1       3-6 

7      8 

1      12 

1     12 

1       8 

5    12 

1        9 

1       6-5 

1       2-4 

7      7 

1        9 

1       9 

1       7-8 

1        4 

7      6 

1        4 

1       4 

1       7-6 

5    11 

1        4 

1       4 

1       2-2 

7      5 

2        2 

I     10-5 

1       7-4 

5      6 

1        8 

1       8 

1       1-2 

1        3 

5      5 

1        0 

1       0 

1       1 

7      4 

1        3 

1       3 

1       7-2 

5      4 

1        0 

1       0 

1       0-8 

7      3 

1        9 

1       9 

1        7 

4    11 

1        0 

1       0 

0     15 

7      2 

1        9 

1       9 

1       6-8 

3      4 

1        3 

1       3 

0     10-4 

724  RELATIVE   WEIGHTS   OF  THE   PLACENTA   AND   CHILD.         [FEB. 

TABLE  III.— Continued. 


Weight 
Placenta. 

Weiglit  of 
Child. 

Average 

Weight  of 

Child. 

Proportional 

Weight  that 

the  Child 

should  be. 

Weight 

of 
Placenta. 

Weight  of 
Child. 

Average 

Weight  of 

Child. 

Proportional 

Weight  that 

the  Child 

should  be. 

lbs.    oz. 

lbs.     oz. 

lbs.    oz. 

lbs.     oz. 

lbs.    oz. 

lbs. 

oz. 

lbs.     oz. 

lbs.    oz. 

2      2 

8       8 
7        5 

7     14-6 

10       9-25 

1      7 

7 
6 

1 
7 

2      0 

9       8 

8     10-5 

9     15'29 

6 

6 

7      13 

1      6 

8 

4 

7       4-2 

6     13-61 

1    15 

9        4 

9       4 

9     10-29 

7 

14 

1     14 

9        6 

9       5 

9       534 

7 

0 

1    12 

8      10 
8       0 

7     16-76 

8     1138 

6 
6 

"s 

7      13 

1      5 

6 

3 

6       3 

6       8-64 

7        8 

1      4 

8 

2 

6     12-6 

6       3-56 

1     11 

8      10 
8      10 
8       8 

8       9-3 

8       6-4 

7 

7 
6 

12 
6 
14 

1      9 

9       2 

8       4 
7      11 
7        7 
7        3 
7        2 

7       6-4 

7     12-46 

6 
6 
6 
6 
5 
5 

11 
10 
8 
7 
12 
11 

7        0 

1      3 

7 

5 

6       3-3 

6     14-68 

6        8 

7 

4 

6      12 

6 

14 

1      8 

8        3 
7      15 
7        0 

7       0-5 

7       7-47 

6 
6 
3 

7 
2 
4 

6      14 

1      2 

6 

15 

6     13 

6       9-6 

6      13 

6 

11 

5        6 

1      0 

6 

3 

5       5-75 

4     16-65 

1      7 

9      10 
8      14 
8      12 

7      136 

7       2-49 

5 
6 
4 

5 
4 
11 

VII.— THE  TREATMENT  OF  DIPHTHERIA  IN  CHILDREN  BY 
STEAM  MEDICATED  WITH  SULPHUROUS  ACID. 

By  T.  Wtld  Pairman,  L.R.C.P.  &  S.  Ed.,  Te  Awamutu,  Auckland,  N.Z. 

{Eead  before  the  Edinburgh  Medico- Chirurgical  Society,  19<A  December  1888.) 

A  VERY  material  hindrance  to  the  successful  treatment  of  diph- 
theria in  children  is  the  difficulty  one  experiences  in  painting  the 
throat  with  the  requisite  antiseptic.  The  operation  is  a  delicate 
one  for  the  experienced  practitioner,  and  doubly  so  for  those 
unaccustomed  to  the  handling  of  children  under  disease.  Indeed, 
it  becomes  a  matter  of  doubt  whether  in  some  cases  the  throat  had 
better  remain  unpainted  rather  than  frighten  the  children  to  the 
verge  of  convulsions.  Again,  when  the  management  is  left  to 
parents  and  nurses,  the  painting  is  usually  done  in  a  very  per- 
functory and  unsatisfactory  manner ;  consequently,  the  proper 
action  of  the  medicament  is  lost.  What  is  wanted  is  a  method 
whereby  the  child  may  lie  undisturbed  during  the  process  of  treat- 
ment, so  as  to  obtain  the  full  benefit  of  a  very  important  factor — 
rest.  It  is  my  firm  belief  that  the  want  of  general  and  local  rest 
is  one  main  cause  for  the  great  mortality  attending  this  disease. 
One  can  scarcely  be  surprised  at  the  extreme  debility  which  ordi- 


1889.]  TREATMENT   OF   DIPHTHEKIA  IN   CHILDREN,  725 

narily  accompanies  diphtheria  when  he  remembers  that  the  child 
is  awakened  every  two  or  three  hours  for  the  purposes  of  treat- 
ment. Should  the  larynx  become  affected,  the  dif&culties  attend- 
ing the  management  are  very  much  increased.  Atomisers  are 
useful  in  such  cases,  but  in  epidemics  the  demand  far  exceeds 
the  supply,  and  I  have  never  found  them  very  efficient  with 
children. 

With  your  permission,  I  shall  give  you  my  experience  of  a 
method — applicable  in  all  forms  of  the  disease — which  has  proved 
extremely  successful  in  my  hands  during  a  severe  and  recent 
epidemic.  Let  me  first  refer  to  some  cases  treated  in  the  ordinary 
fashion. 

Case  I. — I  was  called  to  the  first  case  on  the  morning  of  the 
27th  June  1888.  The  patient,  a  girl  aged  6  years,  resident  in  the 
township,  had  been  complaining  for  some  days  previously  of  a  sore 
throat.  She  was  now  in  a  high  fever,  and  on  examination  the 
tonsils  and  pharynx  were  seen  literally  covered  with  a  dirty- white 
leathery  membrane.  I  pronounced  it  diphtheria,  and  gave  the 
following  injunctions,  which  I  then  considered  judicious  treat- 
ment : — Linseed  meal  poultice  to  throat ;  tinct.  ferri  perchloridi  in 
full  doses ;  chlorate  of  potash  and  hydrochloric  acid  gargle,  to  be 
used  every  two  hours  ;  inhalation  of  steam  from  a  jug  of  hot  water 
as  often  as  convenient ;  beef-tea,  etc.,  etc.,  frequently ;  and  sulphur 
fumigations  as  a  disinfectant.  In  the  afternoon  I  substituted  a 
paste  of  iodoform  and  glycerine  for  the  gargle,  a  preparation  I  had 
formerly  seen  act  as  a  charm.  During  the  night  this  treatment 
was  adhered  to,  and  the  patient  appeared  to  her  parents  better. 
But  about  six  o'clock  on  the  following  morning  they  observed  the 
child  had  a  difficulty  in  breathing,  and  I  was  summoned  at  eight. 
The  disease  had  spread  to  the  larynx,  and  asphyxia  was  imminent. 
Tracheotomy  appeared  the  only  indication,  so  I  performed  the 
operation,  with  immediate  relief  to  the  urgent  symptoms.  A  steam 
chamber  was  improvised,  and  I  attended  personally  to  the  patient, 
but  she  expired  from  asthenia  three  hours  after  the  operation. 

Case  II. — A  younger  member  of  the  same  family  was  attacked 
in  a  similar  way  on  the  29th  June.  A  number  of  small  patches 
were  scattered  over  the  surface  of  both  tonsils,  and  these  ultimately 
coalesced  into  one  mass,  and  implicated  the  entire  throat.  I  treated 
him  with  tinct.  fer.  perchlor.  inwardly,  and  various  antiseptics 
locally.  He  strongly  resisted  all  efforts  to  paint  his  throat  me- 
thodically, and  it  was  often  done  in  a  very  indifferent  fashion. 
He  remained  under  my  care  for  a  month,  and  suffered  from 
frequent  dysenteric  attacks,  which  were  extremely  weakening. 
Ultimately  he  recovered  completely,  with  the  exception  of  a 
paralysis  of  one  side  of  the  face  and  partial  blindness  of  one  eye. 

Case  III. — A  girl,  aged  5  years,  a  delicate  child  from  birth,  and 


726  DR   T.   WYLD   PAIRMAN   ON   THE  [FEB. 

not  long  convalescent  from  hooping-cough.  Saw  her  on  8th  July, 
and  discovered  the  fungoid  growth  on  the  left  tonsil  only ;  appa- 
rently a  mild  case,  but  1  treated  her  like  the  others.  She  appeared 
much  better  on  the  9th,  but  during  the  night  of  the  10th  a  relapse 
occurred,  and  on  the  morning  of  the  11th  I  found  the  disease  had 
spread  to  the  windpipe.  Emetics  of  ipecacuanha  were  administered 
without  relief.  The  fumes  from  burning  tar  and  turpentine — a 
favourite  American  remedy — were  unavailing,  and  the  child  died 
in  a  few  hours. 

Case  IV. — A  strong,  healthy  girl  of  3  years  was  attacked  on 
the  8th  July  with  symptoms  of  laryngitis,  and  treated  by  her 
mother  with  vin.  ipecac,  and  tinct.  aconiti.  She  did  not  improve, 
and  I  was  called  in  on  the  10th  only  to  find  her  gasping  for  breath, 
and  the  whole  throat  a  mass  of  diphtheritic  slough.  I  swabbed  out 
the  throat  with  a  solution  of  permanganate  of  potash,  made  her 
inhale  steam  constantly  from  a  jug  of  hot  water,  and  otherwise 
treated  her  in  the  usual  manner.  The  steam  appeared  to  give 
great  relief,  but  she  ultimately  died  from  asphyxia — the  parents 
refusing  to  allow  tracheotomy. 

I  was  now  thoroughly  convinced  that  in  this  epidemic,  at  any 
rate,  the  usual  orthodox  treatment  was  inefficient,  and  as  I  had 
already  observed  the  relief  afforded  by  the  inhalation  of  steam,  I 
determined  to  give  it  a  more  decided  trial. 

Case  V.  soon  presented  itself.  A  boy,  5  years  old,  showed  the 
usual  diphtheritic  symptoms,  and  very  soon  the  larynx  gave  evidence 
of  being  affected.  I  followed  out  Oertel's  plan  of  inhaling  steam 
for  fifteen  minutes  twice  an  hour,  and  attended  also  to  general  and 
local  treatment.  After  a  few  hours,  the  throat  certainly  showed 
signs  of  improvement,  but  the  laryngeal  symptoms  remained  as 
before,  and  about  midnight  I  was  hurriedly  called  to  see  the  child. 
I  found  him  in  the  greatest  distress,  cyanotic,  and  in  immediate 
danger  of  suffocation.  I  erected  a  tent  over  the  child,  and  led  a 
pipe  from  a  boiling  kettle  to  the  bed.  He  was  soon  in  an  atmo- 
sphere of  steam,  and  in  a  few  hours  his  colour  improved  and  he 
became  less  uneasy.  At  the  end  of  thirty-eight  hours  he  coughed 
up  a  cast  of  the  trachea,  and  from  this  time  his  recovery  was 
assured. 

It  now  became  apparent  to  my  mind  that  in  constant  steam 
inhalation  we  possessed  a  very  powerful  remedy,  and  after  treating 
over  25  cases  by  this  method  without  losing  a  single  patient,  I  have 
deemed  the  subject  sufficiently  important  to  bring  before  the  notice 
of  this  Society.  I  have  given  you  the  history  of  five  cases  to 
enable  you  to  judge  the  nature  of  the  disease,  and  to  show  you 
the  inutility  of  the  usual  remedies.  You  will  observe  that  the 
fungoid  growth  in  four  of  these  cases  extended  to  or  began  in  the 
larynx.  This  feature  of  the  epidemic  was  peculiarly  striking, 
more  than  half  of  the  cases  having  shown  laryngeal  symptoms. 


1889.]  TREATMENT   OF    DIPHTHERIA   IN    CHILDREN.  727 

Practitioners  who  have  long  practised  in  this  colony  tell  me 
they  have  often  remarked  that  in  epidemics  the  fungus  appears  to 
choose  a  particular  site  for  its  nidus,  sometimes  attacking  only  the 
pharynx,  and  at  others  extending  to  the  windpipe.  In  this  semi- 
tropical  climate,  also,  the  disease  has  a  very  active  growth,  and 
except  prompt  measures  are  taken  to  arrest  it,  the  effects  are  very 
deadly.  I  have  known  a  clean  tonsil  covered  with  membrane  in 
the  short  space  of  three  hours. 

My  invariable  practice  now,  when  called  to  a  case  of  diphtheria, 
is  to  erect  a  tent  over  the  head  of  the  sufferer  by  fixing  to  the  bed 
an  open  umbrella,  and  throwing  over  this  a  large  sheet.  I  then 
procure  6  feet  or  so  of  zinc  spouting,  which  can  be  readily  detached 
from  the  dwelling-house,  punch  a  hole  in  its  length,  and  fit  the 
mouth  of  an  ordinary  kettle  into  it.  One  end  is  tilted  up  and 
placed  under  the  tent,  the  bed  being  situated  at  right  angles  to 
the  fender,  and  if  the  kettle  contain  water  at  no  higher  level  than 
the  inner  spout-hole,  steam  will  at  once  proceed  up  the  pipe  into 
the  tent.  With  this  steam  treatment  1  usually  combine  mild 
antiseptic  fumes,  obtained  by  burning  sulphur  in  the  apartment. 
Nothing  more  is  required.  Should  the  patient  be  an  adult,  I  may 
order  the  throat  to  be  painted  with  an  antiseptic  three  or  four 
times  a  day,  but  this  is  not  at  all  necessary.  I  have  successfully 
treated  many  simply  with  the  steam  and  sulphur  fumes,  and  some 
of  the  cases  have  been  of  a  very  virulent  type.  As  a  prophylactic 
during  convalescence,  I  advise  the  use  of  some  chlorate  of  potash 
preparation.  Let  me  refer  to  one  other  case  as  illustrative  of  my 
remarks. 

Case  VI. — At  3  p.m.  on  the  3rd  September  1888, 1  was  asked  to 
visit  a  child,  5  years  old,  who  had  been  ill  for  some  days.  Her 
father  stated  that  she  was  in  a  burning  fever,  delirious  at  times, 
unable  to  swallow,  and  had  a  difficulty  in  breathing.  I  visited 
her  at  once,  and  recognised  the  nature  of  the  case.  Both  tonsils 
were  covered  with  the  fungus,  and,  judging  from  the  respiration, 
the  larynx  was  only  slightly  affected.  I  rigged  up  the  tent  and 
apparatus  already  described,  and  left  my  injunctions  with  a  trained 
nurse.  These  were,  to  keep  the  steam  going  constantly,  to  burn  a 
teaspoonful  of  sulphur  every  hour,  and  to  let  the  patient  have  as 
much  milk  as  she  could  drink,  as  well  as  beef-tea,  chicken  broth, 
et  hoc  genus  omne.  At  seven  o'clock  she  fell  into  an  uneasy  slumber, 
and  awoke  at  10  much  better,  partook  of  a  good  draught  of  milk, 
and  said  she  liked  the  steam.  At  midnight  she  fell  into  a  deep, 
natural,  and  soothing  sleep,  and  awoke  at  seven  on  the  following 
morning  with  all  the  bad  symptoms  gone,  and  an  intense  craving 
for  food.  I  saw  her  at  three  o'clock  in  the  afternoon,  exactly 
twenty-four  hours  after  my  first  visit,  and  she  appeared  perfectly 
well.  I  examined  the  throat ;  the  fungus  had  gone,  and  the  only 
sign  to  show  there  was  anything  wrong  was  an  enlargement  of  the 


728  TREATMENT   OF   DIPIITIIEIUA   IN   CIIILDKEN.  [FEB, 

tonsils,  and  an  excavation  in  each  showing  where  the  enemy  had 
been  rooted  out.  The  nurse  informed  me  that  the  fever  began  to 
abate  about  tlireo  liours  after  commencing  the  treatment,  and  liad 
entirely  left  by  midnight.  I  then  stopped  the  steam  supply,  ordered 
the  room  to  be  kept  warm,  and  gave  the  patient  a  few  compressed 
tablets  of  chlorate  of  potash  to  suck  slowly  for  some  days. 

This  case  is  a  fair  type  of  many  that  I  have  treated  in  a  similar 
manner,  with  equally  gratifying  and  remarkable  results. 

I  will  conclude  by  enumerating  some  of  the  advantages  of  this 
method  of  treatment. 

1.  Constitutional  and  local  rest  are  obtained  during  the  whole 
course  of  the  disease. 

2.  The  steam  acts  as  a  very  efficient  poultice.  We  may  con- 
sider the  fungoid  growth  essentially  as  a  slough  which  requires  to 
be  removed,  though  not  forcibly  torn  away.  To  assist  its  removal 
heat  and  moisture  are  applied,  as  we  would  apply  a  poultice  to  any 
slough  elsewhere.  Furthermore,  the  antiseptic  reaches  the  active 
micrococci,  which  are  most  abundant  in  the  underlying  tissues. 

3.  The  method  is  applicable  in  all  forms  of  the  disease.  Even 
in  cases  where  the  air-passages  were  very  much  involved,  I  have 
seen  great  relief  in  a  few  hours,  but  usually  some  days  are  neces- 
sary to  effect  a  cure. 

4.  Very  little  apparatus  is  required,  and  the  method  is  extremely 
simple.  This  is  an  important  point  in  country  practice,  especially 
in  the  colonies,  where  one  is  often  driven  to  extremities  for  suit- 
able appliances.  Oertel's  plan  is  not,  in  my  opinion,  sufficient. 
It  is  like  allowing  a  poultice  to  become  cold,  which  then  may  do 
more  harm  than  good. 

5.  Paralysis  seems  never  to  occur  as  a  sequela. 

6.  Patients  very  seldom  complain  of  any  sore  throat,  and  are  able 
to  swallow  food  with  little  or  no  inconvenience. 

In  conclusion,  the  method  may  appear  an  extremely  weakening 
process,  but  I  have  never  found  it  so.  Convalescence  is  very  rapid  ; 
and  in  my  experience,  if  proper  precautions  are  taken  against  cold, 
no  bad  effects  have  followed,  even  in  cases  where  children  have 
breathed  steam  four  days  and  nights  successively. 


VIIL— ENCYSTED  SEROUS  PERITONITIS,  OR  EFFUSION  OF 
SERUM    CONSEQUENT    UPON    PERITONITIS    AND    CON- 
FINEMENT OF  THE  FLUID  BY  ADHESIONS. 
By  James  Oliver,  M.D.,  F.R.S.  (Edin.) 

The  peritoneum,  and  especially  that  part  of  it  which,  entering 
into  the  formation  of  the  pelvis,  covers  more  or  less  completely 
the  organs  contained  within  this  cavity  is,  of  all  the  serous  mem- 
branes of  the  body,  that  most  prone  to  produce  cystic  formations 


1889.]  ENCYSTED    SEROUS   PERITONITIS.  729 

in  consequence  of  inflammation  of  its  structure.  In  order  that 
definable  tumours  of  a  cystic  nature  may  develop  in  tliis  manner, 
there  must  have  resulted,  prior  to  the  effusion  of  fluid,  not  only  a 
thickening  of  the  inflamed  tissue,  but  an  adhesion  more  or  less 
extensive  and  complete  of  opposing  surfaces.  The  pre-existing 
thickening  and  adhesion  is  the  product  of  connective  tissue  cell 
proliferation,  whilst  the  effusion  is  the  result  of  an  interstitial 
exudation.  Under  such  circumstances,  the  fluid  contains,  as  a 
rule,  but  a  small  amount  of  fibrin.  The  number  of  young  cells 
present  vary,  but  they  exist  always  in  greater  or  less  abundance. 
The  transition  from  serum  to  pus  is  a  gradual  one — the  latter 
fluid  is  essentially  the  product  of  the  former — the  young  cells 
being  simply  more  abundant.  The  effusion  of  fluid  subsequent 
to  an  attack  of  pelvic  peritonitis  is  determined  by  some  occult 
constitutional  state,  either  existing  before  or  arising  during  the 
evolution  of  the  inflammatory  disorder.  A  close  scrutiny  of  the 
clinical  history  in  such  cases  will  often  reveal  facts  indicative  of 
a  disposition,  at  least,  to  some  constitutional  deterioration.  Case 
II.,  recorded  hereafter,  is  in  this  respect  one  worthy  of  note.  The 
woman  is  27  years  of  age.  She  has  already,  during  her  four  years 
of  marital  life,  given  birth  to  three  full-time  children,  all  females, 
and  yet  not  one  of  these  is  alive.  The  first  lived  but  two  hours, 
the  second  was  still-born,  whilst  the  third  lived  four  weeks.  This 
female  had  the  power  to  bring  forth  full-time  children — these,  how- 
ever, were  feebly  viable,  and  readily  succumbed.  The  mother  had 
apparently,  on  account  of  some  occult  agency  at  work,  failed  to 
endow  her  offspring  with  sufficient  energy  to  enable  them  to 
carry  on  a  partially  independent  existence.  In  the  case  of  animals 
kept  under  confinement  it  is  a  well-known  fact  that  many  of  their 
young  are  either  born  dead  or  die  very  soon  after  birth,  and  this 
in  consequence  of  some  occult  constitutional  deterioration,  although 
the  parents  may  never  have  evinced  any  decided  manifestation 
of  such.  A  broken-down  constitution,  so  to  speak,  may  therefore 
be  an  association  of  encysted  serous  formations  consequent  upon 
pelvic  peritonitis. 

Pathology. — It  is  but  seldom  that  an  opportunity  is  afforded  for 
the  examination  of  the  structures  involved  in  encysted  serous 
peritonitis.  The  cystic  formations  are,  however,  always  preceded 
by  symptoms  and  physical  signs  indicative  of  inflammation  of 
the  serous  lining  of  the  pelvis ;  the  morbid  anatomy,  therefore,  of 
the  disorder  in  question  is  essentially  the  same  as  that  of  inflam- 
mation of  any  other  like  structure  in  the  body.  There  is  noted 
first  a  redness  of  tissue  due  to  increased  vascularity,  and  here  and 
there  haemorrhagic  spots,  it  may  be  in  consequence  of  the  rupture 
of  vessels  and  extravasation  of  blood.  The  surface  of  the  mem- 
brane thereafter  assumes  a  dull  appearance  instead  of  presenting 
its  characteristic  gloss.  It  becomes  studded  with  fine  villi  and 
papilla3  as  a  result  of  a  proliferation  of  the  connective  tissue  cells, 

EDINBURGH   MED.^JOURN.,   VOL.    XXXIV. — NO.    VIII.  4  Z 


730  DR  JAMES   OLIVER   ON  [FEB. 

and  these  eventually  end  in  the  production  of  pseudo-membrane 
and  adhesions.  In  many  cases  of  pelvic  as  well  as  general  peri- 
tonitis there  results  an  effusion  of  serum.  If  the  fluid  is  free,  it 
gravitates  to  the  most  dependent  parts,  and  therefore  alters  its 
location  according  to  the  position  of  the  patient.  If  the  serous 
exudation  is  abundant  but  confined  by  adhesions,  which  have 
been  developed  prior  to  the  occurrence  of  the  effusion,  one  or 
more  distinct  and  palpable  tumours  may  thus  be  produced.  To 
these  swellings  we  apply  the  term  encysted  serous  peritonitis. 
The  fluid  poured  out  under  such  circumstances  is,  as  a  rule,  free 
from  flaky  deposit,  and  in  this  respect  is  very  different  to  that 
poured  out  during  a  more  or  less  acute  attack  of  inflammation  of 
the  peritoneum. 

Etiology. — The  primary  factor  at  work  in  the  production  of  any 
disorder  is  difficult  to  determine.  Different  individuals  exposed 
to  like  conditions  in  the  same  place  and  at  the  same  time,  although 
living  under  very  similar  circumstances,  may  be  variously  afflicted. 
Functional  disturbance  and  structural  vulnerability, it  would  appear, 
is  in  each  case  determined  by  some  occult  constitutional  state  of 
the  organism.  Thus  many  inflammations  are  attributable  to  cold, 
and,  doubtless,  this  is  frequently  the  exciting  cause  of  inflamma- 
tion of  the  pelvic  peritoneum.  What,  however,  determines  a 
progressive  effusion  of  serum  in  any  given  case  of  pelvic  peritonitis, 
long  after  the  inflammatory  disorder  has  apparently  subsided,  I 
am  unable  to  apprehend.  Clinical  facts  teach  us  that  the  serous 
lining  of  the  pelvis  is  more  vulnerable,  and  therefore  more 
prone  to  become  the  seat  of  inflammatory  disturbance,  either 
immediately  before  or  during  menstruation.  Mere  augmented, 
functional  activity  increases  the  susceptibility  of  such  a  highly 
organized  structure  to  disorder.  The  serous  membrane  in  the 
pelvis  is  often  secondarily  involved,  because  of  a  direct  contiguity 
of  tissue,  the  inflammation  attacking,  primarily,  either  the  uterus 
itself  or,  it  may  be,  the  Fallopian  tube.  An  alleged  exciting  cause 
of  pelvic  peritonitis  may  be  considered  part  cause,  in  a  given 
case,  of  that  form  of  inflammation  of  this  structure  which  results 
in  the  formation  of  one  or  more  loculi,  into  which  there  is  poured 
a  greater  or  less  amount  of  serum,  and  there  is,  in  consequence, 
produced  a  distinctly  cystic  tumour  of  larger  or  smaller  dimensions. 
The  size  which  such  swellings  may  attain,  considering  their  mode 
of  development,  is  almost  incredible,  and  I  have  seen  them  equal  in 
hardness  and  resistance  to  that  of  any  fibroid  growth  of  the  uterus. 
Under  such  circumstances  the  fluid  tension  is  exceedingly  great 
and  the  confining  walls  extremely  thick. 

The  differential  diagnosis  of  encysted  tumours  of  the  peritoneum 
is,  as  a  rule,  no  easy  task.  In  the  majority  of  cases  a  well-sifted 
clinical  history  will  prove  helpful ;  we  must  not,  however,  rely 
too  exclusively  upon  this.  Extensive  inflammation  of  the  pelvic 
peritoneum  may  not  only  arise,  but  progress  so  insidiously  that 


1889.]  ENCYSTED   SEROUS   PERITONITIS.  731 

the  patient,  because  of  the  paucity  and  inseverity  of  the  symptoms, 
cannot  believe  she  is  the  subject  of  a  grave  disorder,  and  she  seeks 
advice,  eventually  it  may  be  on  account  of  some  very  indefinite  but 
constant  pain  or  uncomfortable  feeling.  A  dogmatic  conclusion 
can  only  be  arrived  at  after  careful  observation  and  due  considera- 
tion of  all  facts,  clinical  as  well  as  physical. 

A  comprehensive  and  at  the  same  time  intelligible  description 
of  the  symptoms  apt  to  arise  in  association  with  encysted  serous 
peritonitis  is  impossible.  Instead  of  attempting  such  a  tabula- 
tion, I  have  deemed  it  more  expedient,  because  of  the  likelihood 
of  proving  generally  more  profitable,  to  record  in  extenso  two  very 
typical  cases  of  the  disorder  which  have  recently  been  under  my 
care. 

Case  I. — Encysted  Serous  Peritonitis. — E.  E.,  aet.  20,  single,  a 
dressmaker,  came  under  my  care  at  the  Hospital  for  Women  on 
18th  September  1886.  She  then  complained  of  pain  all  over  the 
lower  abdomen,  but  referred  more  especially  to  the  right  side, 
and  which  radiated  down  the  inside  of  the  right  thigh  as  far  as  the 
knee.  This  pain  developed  on  the  fourth  day  of  the  last  menstrua- 
tion, and  had  now  been  in  existence  seven  weeks.  The  last  monthly 
flow  appeared  on  the  27th  of  July,  three  weeks  later  than  usual ; 
it  was  then  prolonged  to  the  extent  of  fourteen  days,  but  was  not 
continuous,  neither  was  it  excessive.  As  a  rule,  the  catamenial 
discharge  from  its  first  appearance  at  the  age  of  14  had  continued 
seven  days. 

Bladder. — During  the  first  six  weeks  of  the  present  illness  patient 
had  complained  of  pain  before  and  during  the  act  of  micturition, 
but  now  no  pain  had  been  experienced  for  seven  days: 

Bovjel. — There  is  noted  no  disturbance  referable  to  the  gut. 

The  temperature  is  101°-4  F. 

The  abdomen  throughout,  but  more  especially  in  the  right  iliac 
region,  is  tender  to  the  touch  and  slightly  distended  ;  there  is, 
however,  no  dulness,  neither  evidence  of  effusion. 

Vaginal  examination  reveals  the  presence  of  a  small  amount  of 
plastic  exudation  in  close  apposition  with  the  uterus  on  the  right 
side.  Its  consistence  is  like  unto  that  of  the  pulp  of  a  normal 
spleen. 

ISTo  special  change  is  noted  in  the  condition  of  the  patient  until 
the  5th  of  February,  except  that  the  pains  had  gradually  abated, 
and  now  there  is  experienced  only  occasionally  a  slight  shooting 
pain  in  both  sides  of  the  lower  abdomen. 

On  the  5th  of  February — that  is,  seven  months  after  the  origin 
of  the  pelvic  peritonitis — my  note  of  the  patient's  condition  runs 
thus  : — The  abdomen  is  occupied  by  a  globular  swelling  of  a  some- 
what pyriform  shape,  the  broad  end  of  which  reaches  to  the 
umbilicus.  The  percussion  note  over  the  whole  extent  of  the 
swelling  is  dull.     Fluctuation  in  all  directions  is  readily  elicited. 


732  Dll   JAMES   OLIVER   ON  [FEB. 

The  cervix  is  somewhat  soft,  apparently  oedernatous.  Pressing 
the  abdominal  tumour  downwards  moves  the  cervix  readily,  whilst 
moving  the  swelling  abdominally  from  right  to  left  disturbs  the 
position  of  the  cervix  but  slightly ;  a  left  to  right  movement,  how- 
ever, moves  the  cervix  more  markedly. 

On  the  right  side  of  the  uterus,  in  close  apposition  with  this 
organ,  is  felt  a  small  elongated  mass,  probably  the  original  plastic 
exudation  becoming  organized. 

Occasionally  shooting  pains  are  complained  of  on  both  sides  of 
the  stomach,  and  there  is  experienced  a  slight  pain,  centrally  situ- 
ated, towards  the  end  of  passing  water.  There  is  no  frequent 
desire  to  pass  water. 

February  26. — The  abdominal  swelling  is  practically  unaltered. 
The  uterus  is  beginning  to  be  drawn  somewhat  to  the  right  side  of 
the  pelvis,  in  consequence  of  a  retraction  of  the  newly-formed 
fibrous  tissue  resulting  from  the  plastic  exudation  already  de- 
scribed.    The  temperature  is  normal. 

April  2. — The  abdominal  swelling  is  much  reduced  in  size, 
reaching  only  to  midway  between  the  pubes  and  umbilicus.  The 
plastic  exudation  on  the  right  side  of  the  uterus  is  much  smaller, 
whilst  the  deviation  of  this  organ  to  the  right  side  is  consequently 
more  marked. 

May  7. — There  is  now  no  trace  of  the  cystic  swelling,  and  the 
uterus  is  closely  applied  to  the  right  wall  of  the  pelvis. 

Throughout  the  existence  of  the  abdominal  tumour  the  pains 
complained  of  were  hardly  worthy  of  note. 

From  January  menstruation  recurred  regularly  every  month, 
and  was  free  from  associated  pain ;  the  quantity  lost  was  as 
usual,  so  also  was  the  duration  of  the  discharge,  viz.,  for  seven 
days. 

Case  II. — Encysted  Serous  Peritonitis  (patient  became  pregnant 
soon  after  the  disappearance  of  the  cystic  formation). — E.  A., 
cX3t.  27,  married  four  years,  came  under  my  care  on  the  4th  of  April 
1888.  She  had  given  birth  to  three  full-time  children.  She  has  had 
no  miscarriages.  All  three  children  were  females :  the  first  lived 
two  hours,  the  second  was  still-born,  whilst  the  third  lived  four 
weeks.     The  last  child  was  born  twelve  months  ago. 

Patient  began  to  menstruate  at  the  age  of  16,  and  the  usual 
duration  of  the  flow  has  been  five  days.  She  was  last  unwell  seven 
days  ago. 

Since  the  birth  of  the  last  child,  twelve  months  ago,  patient  has 
complained  of  pain,  more  or  less  severe,  in  the  lower  abdomen,  on 
the  right  side,  and  associated  with  a  certain  amount  of  "  bearing 
down."  No  pain  has  been  noted  in  the  legs.  Three  or  four  weeks 
ago  patient  detected  a  small  lump  on  the  right  side  of  the  abdomen, 
close  to  the  groin,  which  has  gradually  increased  in  size. 
•  Menstruation  has  always  been  regular.    Patient,  however,  missed, 


1889.]  ENCYSTED   SEROUS  PERITONITIS.  733 

without  apparent  reason,  for  three  months,  from  December  1887 
until  March  1888. 

Bladder. — There  is  experienced  centrally  a  pain  if  the  water  is 
retained  after  the  desire  to  empty  the  bladder  of  its  contents  has 
once  been  invoked.  There  has  also  been  for  the  last  twelve  months 
pain  during  micturition,  and  frequent  desire  during  the  day  to  pass 
urine. 

Rectum. — There  is  no  disturbance  referable  to  the  gut. 

There  is  a  small  cystic  swelling  occupying,  on  the  right  side,  the 
lower  abdomen  and  pelvis.  It  is  about  the  size  of  a  cocoa-nut,  and 
appears  to  be  continuous  with  the  uterus,  as  the  two  move  simul- 
taneously.    Movement  induces  a  severe  aching  pain. 

April  11. — The  abdominal  swelling  is  much  increased;  it 
reaches  the  level  of  the  umbilicus,  but  its  left  border  does  not 
pass  much  beyond  the  umbilical  line  longitudinally.  Fluctuation 
can  be  elicited.  The  tumour  appears  to  be  more  distinct  from  the 
uterus  than  it  was  on  first  examination.  Patient  lies  best  on  the 
right  side ;  if  she  lies  on  the  left  the  pain  is  increased ;  this,  of 
course,  is  explicable  on  the  ground  that  lying  on  the  left  side 
induces  a  more  marked  tension  of  adhesions. 

April  21. — The  cystic  swelling  measures  7  inches  transversely 
and  5  inches  longitudinally.  It  is  more  prominent,  and  extends 
now  to  2  inches  beyond  the  longitudinal  umbilical  line.  Behind 
the  uterus  is  felt  a  small  nodule,  in  close  apposition  with  this 
organ,  which  is  most  probably,  from  its  tactile  impression,  a  plastic 
exudation,  the  consistence  being  like  that  of  the  pulp  of  a  healthy 
spleen. 

April  28. — Patient  has  been  sick  twice  during  the  last  week, 
and  to-day  the  temperature  is  102°  F.,  and  the  pulse  numbers  102. 
The  abdominal  swelling  is  slightly  larger,  and  is  especially  tender 
to  the  touch.  The  swelling  behind  the  uterus,  already  described 
as  a  plastic  exudation,  is  extremely  sensitive,  the  merest  touch 
inducing  severe  pain.  This  week  patient  has  complained  of  more 
pain,  and  of  an  accessory  pain  shooting  into  the  vagina  centrally 
from  the  abdomen.  The  pain  already  complained  of  during  mic- 
turition is  also  augmented. 

May  9.— Morning  temperature,  101°  F. ;  evening,  102°-4  F.  The 
swelling  is  less  prominent,  but  quite  as  extensive.  Patient  lies 
best  on  the  right  side ;  if  she  lies  on  the  left  pain  is  intensified. 

May  17. — Morning  temperature,  99°  F. ;  evening,  100°  F.  The 
abdominal  swelling  has  materially  decreased  during  the  last  eight 
days. 

May  24. — Temperature  has  been  normal  for  three  days.  No 
evidence  of  the  pre-existing  abdominal  swelling  is  now  to  be 
detected.  A  slight  thickening  is  detected,  extending  from  the 
right  wall  of  the  pelvis  to  the  right  side  of  the  uterus. 

June  13. — The  uterus  is  drawn  rather  to  the  right  side  of  the 
pelvis. 


734  DR   JAMES   OLIVER  ON  [FEB. 

July  4. — Patient  during  the  last  few  days  has  noted  that  imme- 
diately she  drinks  anything  hot  a  pain  of  a  sharp  stabbing  character 
is  radiated  from  the  left  to  the  right  side  of  the  lower  abdomen. 
There  is  now  no  pain  on  voiding  urine,  neither  is  there  frequent 
desire  to  empty  the  bladder  of  its  contents. 

Vaginal  Examination. — The  cervix  is  directed  backwards  and 
to  the  left  side,  whilst  the  fundus  is  easily  detected  in  front  and  to 
the  right  side.  The  left  border  of  the  uterus  corresponds  as  nearly 
as  possible  with  the  longitudinal  mesial  line  of  the  body,  whilst  the 
space  between  the  right  border  and  right  pelvic  wall  is  occupied 
by  deposit.  The  vaginal  roof  on  the  left  side  of  the  cervix  is 
tense,  whilst  that  on  the  right  is  markedly  plicated,  as  though  it 
were  badly  adapted  to  the  retraction  going  on  in  this  side. 

Oct.  9. — Patient,  who  during  the  existence  of  the  cystic  swelling 
had  been  quite  regular,  has  not  been  unwell  for  ten  weeks.  Two 
months  ago  there  was  a  feeling  of  sickness  after  each  meal,  and 
this  sensation  persisted  till  seven  days  ago.  There  is  no  pain, 
except  when  she  is  compelled  to  hold  the  water  too  long.  For 
three  weeks  the  breasts  have  been  enlarging.  The  uterus  is 
enlarged,  and  evinces  all  the  characters  of  utero-gestation.  It  is 
drawn  bodily  to  the  right  side. 

In  the  cases  I  have  recorded  it  is  probable  that  the  fluid  effused 
was  contained  in  a  cavity  bounded  by  that  peritoneum  covering  the 
uterus  and  various  parts  of  the  gut  as  well  as  lining  the  pelvis  and 
lower  part  of  the  abdomem.  In  the  Gazette  Medicate  de  Paris,  1851, 
p.  641,  M.  Forget  of  Strasburg  records  the  autopsy  of  a  case.  Seven 
years  previously  the  woman  was  supposed  to  have  been  the  subject 
of  ovarian  dropsy,  and  on  four  occasions  she  had  been  tapped.  At 
the  age  of  sixty-two  she  died  of  cancer  of  the  body  of  the  uterus. 
On  opening  the  abdomen,  the  ovarian  cyst  turned  out  to  be  a  cyst 
bounded,  or  rather  the  anterior  wall  of  which  was  formed  by  great 
omentum  thickened  and  adherent  to  the  anterior  wall  of  the 
abdomen  ;  the  posterior  wall  was  formed  by  coils  of  small  intestine 
firmly  adherent  and  covered  by  false  membrane,  whilst  the  floor 
of  the  cavity  was  composed  of  structures  recognised  as  remnants 
of  the  uterus  and  ovaries.  Cystic  formations  consequent  upon 
pelvic  peritonitis  are  rare,  and  dissections  of  such  cases  still  rarer, 
as  they  seldom  end  fatally,  consequently  it  is  impossible  to 
dogmatize  regarding  the  structures  which  enter  into  the  formation 
of  such  cysts.  The  ovary  may  and  does  undoubtedly  undergo 
cystic  change  occasionally  when  imbedded  in  an  inflammatory 
exudation.  Four  years  ago  I  tapped  through  the  vagina  a  tumour 
containing  a  pint  of  yellowish  serum,  and  occupying  the  left  side  of 
the  pelvis,  which  1  surmised  had  been  formed  in  this  way.  The 
patient  thereafter  made  a  good  recovery,  therefore  it  is  impossible 
to  say  whether  my  surmise  was  correct,  probably  it  too  ought  to 
have  been  considered  a  case  of  encysted  serous  peritonitis. 


1889.]  ENCYSTED   SEROUS  PERITONITIS.  735 

Finally,  let  me  say  a  word  with  regard  to  treatment, — Where 
internal  remedies  fail,  but  only  after  a  very  extended  trial,  I  am 
persuaded  that  paracentesis  will  prove  useful.  The  safety  as 
regards  the  ultimate  result  depends  partly,  however,  upon  the 
exclusion  of  air;  I  should  therefore  recommend  the  method  of 
suction.  The  chief  indication  throughout  is  to  improve  the  general 
health,  and  to  attain  this  a  variety  of  accessories  may  be  em- 
ployed. 


l^Hxt  ^econm. 


KEVIEWS. 

Arsberdttelse  /ran    Sabhatsbergs   SJukhus   i   Stockholm   for    1887. 
Afgifven  af  Dr  F.  W.  Warfvinge. 

Record  of  Practice  in  the  Hospital  of  Sabhetsberg  at  Stockholm  for 
1887.  By  Dr  F.  W.  Warfvinge,  Director  and  Superintendent 
of  the  Medical  Department. 

In  this  Hospital,  which  contains  340  beds,  there  were  received  in 
1886, 3138  cases,  of  which  263  were  remainders  of  the  preceding  year, 
and  2S70  admitted  during  the  year.  Of  these,  1653  were  treated  in 
tlie  medical  wards  under  Dr  Warfvinge,  while  1233  were  in  the  sur- 
gical department  under  Dr  Svensson,  and  247  were  in  the  gynae- 
cological section  under  Professor  Netzel.  Of  all  these,  2441  were 
cured  or  relieved,  172  were  dismissed  as  incurable  ;  deaths,  251,  or 
8  per  cent.  The  number  of  days  of  maintenance  was  99*363.  The 
daily  expenditure  for  each  patient  was,  average,  1  kron  47  ore 
(2  fr.  4  c),  of  which  38|  ore  (50  c.)  for  medicines ;  8|  ore  (11  c.) 
lights — electric  1*2  c,  or  0*88  ore.  After  a  summary  account  of 
the  diseases  treated  in  the  three  divisions;  a  short  notice  is  given 
of  over  1000  operations  performed  in  the  surgical  wards,  and  139 
in  the  gynsecological. 

Some  special  relations  of  cases  are  given  by  the  medical  men  in 
charge  of  the  Hospital.  The  first  is  a  very  interesting  notice  of 
fatal  hsemorrhage  from  a  mediastinal  tumour,  which  appeared  in- 
stantaneously at  3.30  P.M.  in  a  delicate  spinster  of  43.  At  7.30 
the  same  day  she  came  to  the  Hospital  ;  could  leave  the  carriage 
and  walk  up  stairs  into  the  receiving  room,  breathless  and  cyanotic  ; 
fainted  in  going  to  the  ciiamber,  and  though  tracheotomy  was  per- 
formed and  a  canula  introduced,  she  respired  two  or  three  times, 
then  died  ten  minutes  after  her  reception.  The  autopsy  revealed 
a  tumour  of  fresh  extravasated  blood  extending  under  the  clavicle 
and  sternum  to  the  pectoral  cavity,  where  it  stopped  at  the  level  of 
the  arch  of  the  aorta,  compressing  the  great  veins ;  no  lesions  in  the 


736  RECORD   OF   PRACTICE   IN   STOCKHOLM   FOR   1887.  [FEB. 

liirge  pectoral  vessels,  but  in  the  anterior  mediastinum  a  tumour 
w;is  found  the  size  of  an  apple,  of  medullary  consistence,  with  the 
anterior  part  lacerated  by  the  luemorrhage.  Compression  of  heart 
and  larr^e  vessels  was  the  probable  cause  of  death. 

Dr  Perman  reports  this  case,  which  Dr  E.  G.  Johnson  follows 
up  by  an  important  paper,  "  Studier  ofver  lopet  i  menniskans  mage 
under  patologiska  forhUlIanden," — "  Studies  on  the  Rennet  of  the 
Stomach  in  Man  under  Pathological  Conditions."  The  above- 
mentioned  researches  were  commenced  in  the  clinique  of  Professor 
B-iegel  at  Giessen,  and  completed  at  Stockholm.  On  24  patients 
researches  were  made  as  to  the  presence  of  the  milk-coagulating 
ferment  and  the  pathological  and  relative  circumstances.  Fourteen 
of  these  suffered  from  hyperacidity,  complicated  in  4  cases  with 
moderate  gastric  dilatation  ;  in  1  of  the  latter  peracidity  was 
combined  with  hyper-secretions  of  the  gastric  juice,  1  case  compli- 
cated with  chlorosis,  3  of  hyperacidity  suffered  from  gastric  ulcers. 
The  author  had  occasion  to  examined  cases  of  hyperacidity  without 
over-secretion  of  gastric  juice  or  dilatation,  3  of  which  were  chlorotic; 
1  had  catarrhal  icterus.  In  5  suffering  from  carcinoma,  4  had  chronic 
dyspepsia  more  or  less  pronounced.  The  contents  of  the  stomach 
were  extracted  either  fasting  or  from  four  to  six  hours  after  a  tenta- 
tive meal.  No  difficulty  was  experienced  in  obtaining  undiluted 
gastric  juice  in  the  majority  of  the  cases.  There  appeared  no 
diminution  of  coagulating  powers  of  the  gastric  juice  on  milk  from 
dilution.  Experiments  were  made  at  fron  19°'5  C.  to  36°-40°  C. 
Coagulation  effected,  the  serum  was  pressed  out,  examined  for 
lactic  acid ;  it  took  from  four  to  fifty  minutes,  a  little  longer  when 
the  milk  was  boiled.  Dr  Johnson  draws  the  following  inferences 
from  his  researches  : — 

1.  Rennet  is  a  permanent  product  of  the  granular  secretions  of 
the  stomach,  and  is  found  in  the  gastric  juice  in  all  the  stages  of 
digestion,  unless  in  cases  of  gastric  carcinoma,  in  which  the  presence 
of  the  milk-coagulating  ferment  has  never  been  ascertained. 

2.  When  the  stomach  has  been  washed  out  on  the  previous 
evening,  and  the  subject  still  fasting,  the  rennet  is  found  in  the 
hypersecretions  of  gastric  juice  all  the  same. 

3.  When  hydrochloric  acid  is  found  in  the  hypersecretions  of 
gastric  juice,  the  greater  or  less  amount  of  this  acid  appears  to  have 
no  influence  on  the  rapidity  or  fulness  of  the  curdling  produced  by 
the  rennet  of  the  neutralized  gastric  juice, 

4.  Rennet  does  not  pass  into  the  urine. 

5.  It  is  easily  destroyed  by  an  excess  of  alkali,  and  it  is  prob- 
ably hence  that  it  does  not  pass  into  the  faeces  under  normal 
circumstances. 

6.  In  the  course  of  fever  it  appears  that  the  coagulating  ferment 
may  become  defective  in  the  contents  of  the  stomach. 

7.  Rennet  seems  to  cause  a  slower  coagulation  in  boiled  than  in 
fresh  milk. 


1889.]  KECORD   OF   PRACTICE   IN   STOCKHOLM   FOR   1887.  737 

8.  In  the  coagulation  of  milk  by  the  human  rennet  the  reaction 
remains  neutral.     No  lactic  acid  is  found  after  coagulation. 

This  important  and  valuable  communication  is  followed  up  by 
the  researches  by  Dr  G.  D.  Wilkens,  entitled,  "  Bidrag  till  kan- 
nedomen  om  blodkropparnes  hos  friska  ock  sjuka," — "  On  the 
Number  and  the  Haemoglobine  of  Blood  Corpuscles  in  the  Healthy 
and  the  Sick." 

By  means  of  the  hsematometer — an  apparatus  devised  by  Pro- 
fessor Fleischl  of  Vienna — the  author  has  experimented  on  the 
intensity  of  the  hsemoglobine  in  the  blood  of  sound  and  sick  men, 
and  of  the  relations  of  the  number  and  of  the  hsemoglobine  of  the 
blood  corpuscles  among  the  diseased.  Of  642  healthy  individuals, 
infants  under  2  months  had  100  per  cent.,  and  above  that  in  ages 
from  12  to  62.  After  the  latter  age  they  again  diminished.  As 
the  result  of  his  observations,  the  author  is  in  accord  with  the 
general  opinion,  that  the  point  at  which  Professor  Fleischl  has  fixed 
the  normal  number  of  100  per  cent,  is  too  low  for  the  inhabitants 
of  Stockholm. 

The  different  maladies  in  which  the  author  has  had  occasion  to 
examine  the  blood  of  the  sick  have  been  divided  by  him  thus : — 
Primary  Ancemia — Chlorosis,  simple  ansemia,  progressive  perni- 
cious anaemia,  purpura  hgemorrhagica,  leucaemia,  pseudo-leucsemia. 
Secondary  Ancemia — Haemorrhages,  typhoid  fever,  acute  croupous 
pneumonia,  intoxications,  acute  articular  rheumatism,  pulmonary 
tuberculosis,  cancer  and  sarcoma,  organic  cardiac  lesion,  diseases 
of  the  digestive  organs. 

As  a  rule,  the  author's  results  have  been  the  same  as  those  fur- 
nished by  the  excellent  experiments  of  Laache,  Engelsen,  and 
Leichtenstein.  In  accordance  with  Laache,  Dr  Wilkens  has  dis- 
criminated simple  primary  anaemia  from  cases  which  were  not  to  be 
classified  as  either  chlorosis  or  pernicious  progressive  anaemia.  In 
the  latter  malady  he  has  found  the  lowest  proportion  per  cent,  of 
hsemoglobine,  namely,  8  per  cent,  nine  hours  before  death.  In 
the  same  disease  Dr  Wilkens  has  found  an  increased  quantity  of 
hsemoglobine  in  relation  to  the  number  of  the  blood  corpuscles  and 
extraordinary  size  of  these.  Difi'ering  from  Leichtenstein,  his  ob- 
servations agree  with  Laache  with  regard  to  typhoid ;  the  blood 
has  betrayed  an  increasing  anaemia,  coming  to  its  maximum  after 
the  cessation  of  the  fever,  then  begins  to  diminish.  One  noticeable 
fact  mentioned  is  that  in  14  cases  of  hysteria  and  neuraesthenia, 
12  presented  a  large  amount  of  hsemoglobine. 

The  result  of  the  various  experiments  is  comprised  in  these  pro- 
positions: The  diseased  organization  does  not  present  constant 
relations  between  the  number  and  the  intensity  of  the  haimoglobine 
of  the  blood  corpuscles.  Unless  where  progressive  pernicious 
anaemia  concerns  a  great  amount,  the  one  corresponds  to  a  large 
quantity  of  the  other,  but  a  small  quantity  of  htemoglobine  relates 
merely  to  a  smaller  or  larger  number. 

EDINBURGH   MED.   JOUKN.,   VOL.   XXXIV. — NO.   VIII.  5  A 


738  RECORD   OF   PRACTICE   IN   STOCKHOLM   FOR   1887.  [FEB. 

Ansemia  which,  as  a  symptom  of  the  blood  diseases,  unless 
chlorosis,  consists  in  a  diminution  of  the  quantity  of  the  hgemoglobine 
of  the  blood  corpuscles  ;  secondary  anssmia  and  chlorosis  are  pro- 
duced by  a  great  and  often  unique  diminution  of  the  quantity  of 
the  former,  and  a  minor  diminution  of  the  corpuscles,  which  often 
remain  at  the  normal  point. 

This  able  paper  is  illustrated  by  numerous  wood  engravings  in 
the  first  style  of  the  art.  The  same  author  has  also  a  case  of  chyluria, 
"  Ett  fall  af  chyluri,"  the  subject  of  which  was  a  Swedish  workman 
of  25,  who  had  never  emigrated,  whose  urine  was  lactiform,  with 
no  other  symptom.  It  contained  fatty  matters  076  to  036,  and 
albumen  0*66  to  0'27.  During  two  weeks'  sojourn  in  the  Hospital,  if 
the  patient  kept  his  bed  and  micturated  hourly,  the  urine  became 
normal,  but  when  he  wrought,  or  after  the  bladder  being  filled  at 
night,  it  became  lactiform  ;  there  were  no  bacteria,  and  the  blood 
presented  nothing  abnormal.  Dr  Wilkens  inclines  to  believe  that 
chyluria  is  a  symptom  of  various  maladies. 

Drs  Svensson  and  Wallis  describe  a  case  of  duodenal  ulceration, 
with  obliteration  of  the  choledochus,  cystic  hepatic  ducts,  and  the 
canal  of  Wirsung.  The  patient  submitted  to  an  operation  made 
with  the  view  of  opening  a  communication  between  the  gall-bladder 
and  the  small  intestine.  The  patient  died  some  days  after,  and  the 
autopsy  revealed  an  ulcer  situated  at  the  common  duct  of  the  duct, 
chol.  and  the  canal  of  Wirsung;  at  the  bottom  of  this  ulcer  was  a 
mass  of  laminated  tissue  that  had  closed  these  all  up,  showing  that 
the  object  of  the  operation  could  not  have  been  attained. 

But  previous  to  these  two  notices  there  is  a  longer  communica- 
tion by  Dr  Perman :  "  Contribution  to  the  Operative  Treatment  of 
Hip-joint  Anchylosis  "('*  Bidrag  till  den  operativa  behandlingen 
af  hoftledsankylos  ").  The  author  relates  two  cases  of  osseous  hip- 
joint  anchylosis  on  which  he  operated,  one  bilateral,  get.  40,  who  at 
4  was  attacked  by  acute  diffusive  osteomyelitis,  resulting  in  bilateral 
osseous  anchylosis,  with  considerable  abduction  of  thighs  and  a 
right-angle  stiffening  of  left  knee.  On  21st  May  1887,  Dr  Perman 
operated  on  Volkmann's  method,  performing  resection  of  right 
haunch,  forming  a  new  acetabulum,  and  rounding  the  superior  ex- 
tremity of  the  femur.  Healed  all  but  a  small  drain  canal  on  the 
29th  May ;  for  a  month  an  extension  bandage  was  used,  as  also 
massage  and  electricity.  On  28th  June  1887,  the  author  operated 
on  left  haunch,  forming  a  subtrochantero-osteotomy,  and  resection 
of  left  knee ;  gypsum  plasters  over  the  whole  limb ;  the  wound 
healed  on  the  7th  July.  At  the  end  of  October  the  patient  left  his 
bed  with  the  plasters  on,  and  began  to  walk  with  a  pair  of  crutches 
like  clothes-horses  of  his  own  devising,  and  by  the  beginning  of 
January  1888  was  able  to  go  about  unaided  on  two  ordinary 
crutches.  On  the  left  side  the  patient  required  a  slight  bandage. 
The  mobility  of  the  articulation  on  the  right  side  good ;  passive 
flexion  to  90°,  abductors  to  40°,  and  active  flexion  to  30°. 


1S89.]  RECORD   OF   PRACTICE  IN   STOCKHOLM   FOR   1887.  739 

The  second  case,  a  blacksmitli  of  28,  was  similarly  treated  on  the 
8tli  September  1887 ;  dismissed  cured  on  14th  December,  and  at 
the  end  of  March  1888  he  could  walk  without  a  stick  and  work  all 
day  at  his  forge.  There  is  an  extensive  purview  of  cases  of  this 
operation  which  have  been  performed  in  Sweden  and  elsewhere, 
and  of  the  various  methods  adopted  he  mentions  his  preference  for 
cuneiform  resection  below  the  grand  trochanter,  and  gives  his  reasons 
for  it. 

The  concluding  article  is  a  paper  by  Dr  Warfvinge  on  "  Clinical 
Experiences  of  Acetphenitidine  and  Antifebrine"  ("  Om  Acetfeni- 
tidin  och  Acetanilid").  As  a  rule,  this  first  medicine  has  been  ad- 
ministered in  59  cases  as  long  as  fever  lasted,  most  frequently  in  half- 
gramme  doses  once  or  twice  a  day,  which  dose  has  acted  decidedly 
febrifugic,  but  not  without  disagreeable  secondary  effects.  Tem- 
perature was  lowered  with  moderate  rapidity,  attaining  its  average 
in  three  hours,  its  minimum  in  two.  In  one-half  of  the  cases  there 
was  considerable  perspiration,  in  the  other  half  little  or  none. 
Only  for  about  an  hour  did  the  temperature  remain  at  its  lowest  point, 
followed  by  an  increase  for  the  same  time,  frequently  accompanied 
by  rigors,  well  marked  in  at  least  one-third  of  tiie  cases,  but  neither 
collapse  nor  cyanosis.     A  roseoloid  eruption  was  once  noticed. 

The  antifebrile  effect  of  this  remedy  was  equally  shown  in 
typhoid,  erysipelas,  pneumonia,  and  phthisis.  In  acute  articular 
rheumatism  it  acted  very  much  inferior  to  salicylic  acid,  but  equal 
to  antipyrin  and  antifebrin  ;  in  mild  cases  it  caused  to  disappear  in 
a  few  days,  not  only  the  fever,  but  the  pain  and  swelling  of  joints 
It  exercised  a  calmative  effect  on  the  irritated  nervous  system.  Dr 
Warfvinge  made  use  of  acetanilid  (antifebrin)  in  187  cases  in  the 
Hospital  of  Sabbatsberg  of  various  maladies  with  and  without 
fever ;  it  manifested  a  considerable  energy  in  lowering  temperature 
even  in  small  doses  from  i  to  ^  gramme,  which  frequently  sufficed  to 
diminish  the  temperature  2°  in  some  hours.  He  treated  continuously 
41  cases  of  typhoid,  and  can  state  that,  when  a  dose  was  given  suffi- 
ciently strong  to  lower  the  temperature  to  normal,  the  effect 
remained  from  seven  to  eight  hours.  After  being  lowered  three 
hours,  it  remained  from  one  and  a  half  to  two  hours  at  its  lowest 
point ;  only  in  one-seventh  of  the  cases  was  there  a  rigor  at  the 
re-elevation  of  the  temperature.  The  dose  of  |  gramme  on  a  pretty 
sharp  case  of  fever  requires  to  be  renewed  from  two  to  four  or  six 
hours  a  day.  In  erysipelas  and  phthisis  the  drug  exercises  a 
relatively  strong  influence,  but  still  more  in  pneumonia.  In  58 
cases  of  acute  rheumatism,  while  inferior  to  salicylic  acid,  it  never- 
theless exercised  a  curative  effect ;  but  in  chronic  rheumatism  it 
was  inert. 

It  displayed  equal  power  with  antipyrine  in  neuralgias  and  other 
painful  affections,  which,  if  it  did  not  always  cause  them  to  entirely 
disappear,  diminished  their  intensity  invariably. 

With  nearly  equal  claims  to  confidence  as  a  febrifuge,  they  are 


740  IIECOIID   OF   PKACTICE  IN   STOCKHOLM   FOR   1887,   ETC.       [FE13. 

both  marked  by  absence  of  disagreeable  secondary  effects ;  while 
antifebrine  is  preferable  as  regards  force  and  moderation  of  doses. 

This  nicely-printed  little  volume  is  illustrated  by  a  well-executed 
view  of  the  Sabbatsbergs  Sjukhus — seven  separated  buildings,  offices, 
and  a  long  corridor  connecting  the  four  posterior  pavilions.  The 
structure  appears  to  combine  every  modern  improvement  and 
amenity ;  while  the  report  of  its  year's  history  gives  us  the  highest 
opinion  of  the  capacity,  energy,  and  devotion  of  its  medical  officers 
and  administrators. 


Congrh  Frangais  de  Ghirurgie.  3°  Session.  Paris,  1888.  Proces 
Verhaux.  M^moires  et  Discussions.  Publics  sous  la  direction  de 
M,  le  Dr  S.  Pozzr,  Secretaire  G^n^ral.  8vo,  pp.  663.  Paris  : 
Felix  Alcan:  1888. 

We  have  in  this  volume  a  collection  of  valuable  surgical  papers, 
representing  the  work  of  the  French  Congress  which  was  held  in 
March  1888.  The  system  of  prescribing  certain  subjects  for  dis- 
cussion, and  having  a  number  of  papers  read  on  each  of  these  sub- 
jects, has  been  carried  out  with  obvious  advantage.  The  four 
subjects  selected  were  as  follow  : — 

(I.)  The  treatment  to  be  adopted  in  gun-shot  wounds  of  the 
abdominal,  thoracic,  and  cranial  cavities  (exploration,  extraction, 
and  various  operations). 

(2.)  Chronic  suppurations  of  the  pleura  and  their  treatment 
(Letr^sant's  and  Estlander's  operations) :  indications,  contra- 
indications, and  final  results. 

(3.)  On  the  value  of  radical  cure  of  hernia,  from  the  point  of  view 
of  permanent  cure. 

(4.)  On  the  return  of  new  growths  after  removal;  researches  into 
the  causes  of  prophylaxis. 

In  addition  to  numerous  papers  on  each  of  these  subjects,  there, 
are  a  large  number  of  important  papers  on  many  questions  of  sur- 
gical interest,  which  will  well  repay  perusal.  We  can  cordially 
recommend  this  volume  as  a  valuable  work  of  reference. 


L' Enseignermnt  et  Vorganisation  de  Vart  Dentaire  aux  Mats-  Unis : 
Rapport  adressi  a  Monsieur  le  Ministre  de  l' Instruction  publique. 
Par  le  Dr  Kuhn.     Paris :  1888. 

What  occasion  there  was  for  a  disquisition  of  some  300  pages  being 
compiled  upon  the  subjects  of  this  volume  at  the  present  day  it  is 
difficult  to  imagine.  The  arguments  in  support  of  insisting  upon 
dentists  being,  like  other  specialists, also  medically  qualified,  or.on  the 
other  hand,  of  excusing  them  from  such  requirements,  are  already 
threadbare.  No  one  would  ever  think  of  denying  that  in  the 
present  position  of  dental  practitioners  there  is  an  amount  of  handi- 


1889.]  L'ENSEIGNEMENT  DE  L'ART  DENTAIRE,   ETC.  741 

craft  expected  of  them  which  demands  a  long  training  and  much 
knowledge  altogether  apart  from  medicine  or  surgery ;  and  if 
thej  were  to  be  restricted  exclusively  to  the  mere  local  treatment 
of  dental  affections,  any  medical  or  surgical  acquirements  necessary 
would  become  almost  infinitesimal.  In  that  way  dentists  would 
scarcely  require  to  qualify  in  a  manner  entitling  them  to  a  medical 
or  surgical  designation  at  all,  and  yet  might  be  in  their  own  sphere 
adequate  and  excellent  practitioners.  But  if  they  wish  to  be 
classified  with,  and  competent  to  work  in  their  own  department 
with  qualified  medical  men, — to  have,  in  fact,  the  status  and  title  of 
"  Surgeons," — something  more  than  this  is  demanded,  and  the  matter 
has  long  ago  been  settled,  at  least  in  this  country.  The  mechanical 
division  of  dentistry — including  in  it  such  operations  as  stopping 
and  the  like — will  always  constitute  the  special  and  distinctive 
prerogative  of  the  dentist,  and  with  it  no  medical  or  surgical 
practitioner  without  dental  training  can  possibly,  or  ever  will,  to  any 
appreciable  extent  interfere.  The  surgical  division,  again,  is  one  in 
which  the  fully  qualified  surgeon  is  bound  to  be  generally  com- 
petent, but  in  which  the  dentist  should  possess  a  special  knowledge 
and  a  more  cultivated  ability  and  experience.  In  Scotland,  where  the 
examinations  for  the  dental  diploma  are  exceptionally  strict,  they 
are  in  the  general  subjects  close  upon  those  for  that  of  surgeon, 
and  in  many  cases  now  the  full  qualification  is  being  taken  out 
along  with  that  of  L.D.S.  This  is  all  that  could  be  desired,  and 
is  in  accordance  with  the  voice  of  the  great  majority  of  the  profession. 
It  is  the  conclusion  come  to  by  the  general  body,  and  is  an  example 
that  dental  waverers  either  in  France  or  the  United  States  could 
not  do  better  than  follow. 


A  Clinical  Handbook  on  the  Diseases  of  Women.     By  W.  Symington 
Brown,  M.D.,  Boston.    New  York :  William  Wood  &  Company 

In  his  preface  the  author  says,  "  This  little  work  does  not  claim 
to  be  a  treatise.  Many  of  the  more  recondite  aspects  of  diseases 
are  purposely  omitted.  It  is  intended  as  a  practical  guide  on 
most  of  the  diseases  peculiar  to  women  for  the  use  of  medical 
students  and  country  practitioners.  An  effort  has  been  made  to 
concentrate  the  best  that  has  been  written  on  each  subject,  includ- 
ing the  old  masters,  whose  works  the  present  generation  are  too 
much  disposed  to  underrate."  The  grammar  displayed  in  this  last 
sentence  may  be  taken  as  an  illustration  of  the  general  style  of 
the  work.  We  cannot  congratulate  the  author  on  his  success  in 
concentrating  the  best  of  the  material  at  his  disposal  any  more 
than  on  the  value  of  the  illustrative  cases  taken  from  his  note- 
books, and  we  would  undertake  to  say  that  an  average  medical 
student  after  having  attended  a  full  course  on  gynascology  could 
produce  a  more  satisfactory  work  on  the  subject.     To  the  profession 


742  HANDBOOK   ON   THE   DISEASES   OF  WOxMEN,   ETC.  [fER. 

at  large  tlie  work  is  not  likely  to  prove  of  any  value.  To  the 
autlior,  however,  it  may  be  useful  in  his  practice,  as  showing  that 
he  is  a  writer  of  a  book  on  the  diseases  of  women. 


On  Curvatures  and  Disease  of  the  Spine.  By  Bernard  E.  Brod- 
HURST,  F.R.C.S.,  Surgeon  to  the  Royal  Orthopcedic  Hospital,  etc. 
Fourth  Edition.     London :  J.  &  A.  Churchill :  1888. 

Throughout  this  book  assertions  are  strong,  but  not  always  well 
founded,  the  principles  of  antiseptic  surgery  are  evidently  not  under- 
stood, and  the  explanation  of  practical  details  of  treatment  are  seldom 
sufficiently  full  to  be  of  service  to  the  practitioner. 

In  discussing  the  subject  of  lateral  curvature  of  the  spine,  the  author 
certainly  gives  a  simple  and  clear  explanation  of  the  rotation  of 
the  vertebrte  which  accompanies  the  lateral  curve.  The  chapter  on 
treatment  of  this  condition,  however,  is  by  no  means  so  good.  Tlie 
instrument  on  which  tlie  author  mainly  relies  for  tlie  good  results 
he  has  obtained  is  not  figured,  and  is  only  described  in  vague,  general 
terms.  Certain  modes  of  treatment  also  are  condemned  while  others 
are  advocated,  but  the  lines  for  their  selection  and  use  are  not  laid 
down  so  definitely  that  one  in  doubt  could  with  any  satisfaction 
turn  to  them  for  help  and  guidance. 

Although  the  work  has  reached  its  fourth  edition,  we  cannot  feel 
that  it  is  at  all  satisfying  nor  likely  to  be  much  run  after. 


Deviations  of  the  Nasal  Septum:  their  Etiology  and  Treatment. 
By  Georqe  Stoker,  Physician  to  the  London  Throat  Hospital, 
etc.     London :  J.  &  A.  Churchill :  1888. 

This  essay,  the  author  informs  us,  is  in  substance  a  lecture 
delivered  by  him  at  the  London  Throat  Hospital.  This  may 
account  for  the  very  elementary  character  of  the  first  few  pages. 
He  proposes  a  classification  which  depends  on  the  clinical  appear- 
ances of  the  deviations.  This,  at  any  rate,  has  the  merit  of  being 
practical.  The  treatment  is  given  in  a  very  lucid  way,  and  though 
everything  the  author  says  is  not  likely  to  be  subscribed  to,  he 
leaves  no  doubt  as  to  wdiat  he  really  means,  and  the  practitioner 
will  get  from  him  a  very  good  idea  of  the  modes  of  relief  in  vogue 
at  present.  To  one  of  his  recommendations  we  decidedly  object. 
It  seems  a  very  cumbrous  way  of  anaesthetizing  a  patient  to 
administer  first  gas,  then  ether,  and  during  the  progress  of  the 
operation  to  "pump  chloroform  into  the  mouth  with  a  Junker's 
apparatus."  We  have  seen  many  operations  on  the  septum  carried 
out  safely  under  the  administration  of  chloroform  alone;  but,  for 
our  own  part,  we  rarely  administer  it  in  the  adult,  cocaine  being 
quite  sufficient  to  prevent  severe  pain.     Further,  we  doubt  if  the 


1889.]  DEVIATIONS   OF   THE   NASAL   SEPTUM,   ETC.  743 

introduction  of  a  piece  of  sponge  into  the  naso-pharynx  facilitates 
the  administration  of  the  angestlietic  as  much  as  Mr  Stoker  claims. 
Its  presence  is  likely  to  increase  the  post-nasal  secretion,  which  is 
always  troublesome  in  operations  on  the  mouth  and  nose. 


On  the  Treatment  of  Cystic  Goitre.  By  T.  Mark  Hovell, 
F.R.C.S.E.,  Senior  Surgeon  and  Aural  Surgeon  to  the  Hospital 
of  Diseases  of  the  Throat.     London  :  J.  &  A.  Churchill :  1888. 

Mr  Hovell  has  done  well  to  reprint  his  paper  read  before  the 
Hunterian  Society.  He  advocates  in  it  the  perchloride  of  iron 
treatment  introduced  by  Sir  Morell  Mackenzie  in  1872.  The 
earlier  part  of  the  essay  is  occupied  by  a  very  complete  discussion 
of  the  details  of  this  method,  the  operative  procedure,  and  the 
after-treatment  of  the  suppuration  which  is  set  up.  Woodcuts  of 
two  cases  operated  on  by  him  in  December  1886  and  January  1887 
show  a  most  admirable  result.  The  remainder  of  the  paper  is 
occupied  by  a  careful  criticism  of  the  conflicting  views  and  recom- 
mendations of  the  various  text-books  and  surgical  authorities. 
We  trust  it  may  do  something  to  advance  the  perchloride  of  iron 
treatment  of  cystic  goitre,  which  is  certainly  one  of  the  safest  and 
most  certain  of  the  various  methods  that  have  been  devised. 


Illustrated  Lectures  on  Amhulance  Work.     By  E,.  Lawton  Roberts, 
M.D.  etc.     Third  Edition.    London  :  H.  K.  Lewis :  1888. 

Former  editions  of  this  book  have  been  already  noticed  in  our 
columns.  It  says  much  for  it  that,  among  so  many  rivals  for  popular 
favour,  a  new  edition  should  be  called  for  in  the  short  space  of  two 
years.  Dr  Roberts  is  evidently  filled  with  the  true  ambulance  spirit. 
He  has  not  attempted  to  make  his  book  a  popular  treatise  on  minor 
surgery,  but  he  has  succeeded  in  producing  one  of  the  best  works 
on  first  aid  and  ambulance  proper  which  we  have  seen,  and  these 
are  not  few.  He  has  added  some  new  illustrations,  and  an  appendix 
containing  information  on  illustrated  triangular  bandages,  pre- 
cautions necessary  in  the  presence  of  poisonous  gases,  rescues  from 
fire  and  drowning,  local  ambulance  corps,  the  St  Andrew's  Ambu- 
lance Association,  and  other  matters  of  importance  to  those  interested 
in  this  great  and  good  work. 


Alpine  Winter  in  its  Medical  Aspects,  with  Notes  on  Davos  Platz, 
Wiesen,  St.  Moritz,  and  Maloja.  By  A.  Tucker  Wise,  M.D., 
etc.     Fourth  Edition.     London  :  J.  &  A.  Churchill :  1888. 

Dr  Wise  has  again  enlarged  his  work  on  the  Alpine  Winter  by 
fresh  matter,  consisting  this  time  of  extracts  from  papers  read  at 


744  ALPINE   WINTER   IN   ITS   MEDICAL   ASPECTS,   ETC.  [FEB. 

the  Harveian  and  Royal  Meteorological  Societies  and  the  Washing- 
ton Congress.  Among  these  additions  are  short  descriptions  of 
Samaden,  Campfbr,  Les  Avants,  and  Arosa,  observations  on  the 
pulse-rate,  respirations  and  chest  expansion,  the  influence  of  ozone 
on  micro-organisms,  a  note  on  the  condition  known  as  mountain 
feverishness,  articles  on  the  etymology  of  the  word  Maloja  and  on 
the  geology  of  the  district,  on  the  pulmonary  conditions  suitable 
and  unsuitable  for  high  altitude  treatment,  and  a  short  record  of 
thirty-three  cases  treated  at  Maloja.  Meteorological  observations 
from  1883  to  1888,  and  a  section  on  summer  excursions  complete 
the  volume,  which  is  one  that  no  physician  interested  in  the  climatic 
treatment  of  phthisis  can  do  without. 


The  Retrospect  of  Medicine.  Vol.  XCVIII.,  July  to  December  1888. 
Edited  by  James  Braithwaite,  M.D.,  London.  London : 
Simpkin,  Marshall,  &  Co. :  1889. 

Braithwaite  is  a  work  which  commands  our  sincerest  admiration. 
In  spite  of  younger  rivals,  it  still  holds  its  own  as  the  book  for  the 
busy  practitioner.  The  cream  of  the  best  papers  of  some  of  the 
best  journals  in  the  world  is  served  up  in  a  way  that  ought  to 
tempt  the  most  jaded  palate.  As  journals  increase  and  medical 
men  become  more  and  more  afflicted  with  the  cacoethes  scrilendi,  it 
is  a  relief  to  know  that  judicious  selections  from  them  are  made  in 
the  manner  shown  in  these  pages,  evidently  the  result  of  a  long 
familiarity  with  the  collating  process.  Those  of  us  who  read  our 
Braithwaites  faithfully  need  not  be  afraid  of  falling  very  far  behind 
in  our  knowledge  of  general  practice. 


The  British  Journal  of  Dermatology.  Edited  by  Malcolm  Morris, 
London,  and  H.  G.  Brooke,  Manchester.  Nos.  1  and  2.  London : 
H.  K.  Lewis :  1: 


A  JOURNAL  of  cutaneous  diseases  under  the  editorship  of  Erasmus 
Wilson  appeared  twenty  years  since,  and  though  ably  conducted,  the 
number  of  workers  in  this  branch  of  medicine  was  then  so  small,  that 
after  an  existence  of  four  years  it  ceased  to  be  issued.  Germany  and 
Austria,  France  and  America,  have  had  their  monthly,  bi-monthly, 
or  quarterly  magazines  devoted  to  skin  diseases  and  syphilis ;  and 
there  is  good  reason  for  believing  that  Great  Britain  has  now  a  staff  of 
workers  sufficient  to  maintain  a  monthly  journal  of  dermatology 
capable  of  taking  a  high  position.  The  names  of  the  editors  augur 
well  for  the  future  of  the  new  comer,  and  the  original  articles  con- 
tributed are  of  much  excellence. 

Dr  Barlow,  Mr  Jonathan  Hutchinson,  and  Dr  Unna  are  all  authors 
whose  words  carry  weight,  and  the  paper  of  Dr  Marmaduke  Sheild 
is  not  less  valuable  and  suggestive.     Reviews  of  recent  works,  and 


18SD.]  TIIK    BRITISH    JOURNAL   OF    DERMATOLOGY,    ETC.  745 

a  precis,  or  selection  from  other  sources,  make  up  the  rest  of  the 
number.  It  only  needs  the  general  support  of  the  profession  to 
insure  a  well-merited  success. 


University  Medical  Magazine.     By  A.  L.  Hummel,  Philadelphia. 
Vol.  I.,  No.  1,  October  1888. 

The  Editors  of  this  new  publication  give  as  its  raison  d'etre,  that 
they  desire  to  develop  a  "quickened  sense  of  close  touch  with  our 
graduates  in  all  parts  of  the  world."  The  Journal  contains  con- 
tributions from  the  pens  of  professors  of  the  university  and  teachers, 
and  is  to  "create  a  medium  of  communication  between  the  graduates." 
This  first  number  has  interesting  and  valuable  articles  by  Professors 
Hayes  Agnew,  Goodell,  H.  C.  Wood,  Pepper,  and  J.  William  White. 
We  bid  the  Journal  welcome,  and  doubt  not  that  it  has  a  useful  future 
before  it. 


MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY    OF    EDINBURGH. 

SESSION   LXVIIL — MEETING    III. 

Wednesday,  I9th  December  1888. — Prof.  Chienb,  Vice-President,  in  the  Chair. 

I.  Exhibition  of  Pathological  Specimens. 

1.  Mr  A.  Q.  Miller  showed — {a)  A  fracture  of  the  lower 
epiphysis  of  the  femur  produced  by  torsion.  The  patient  was  a 
boy  suffering  from  hip-joint  disease  for  which  amputation  was 
considered  necessary.  The  fracture  occurred  during  the  operation 
while  the  limb  in  an  extended  position  was  being  rotated  outwards. 
The  case  was  of  interest  to  him  because  it  was  the  third  time  this 
accident  had  happened  in  his  hands.  The  first  was  when  he  was  a 
student,  rotating  a  limb  for  Prof  Spence  while  he  was  excising  the 
head  of  the  femur,  and  the  second  when  he  himself  was  amputating 
at  the  hip,  as  in  this  third  case.  A  French  surgeon,  M.  Fer^, 
recently  described  the  case  of  an  old  woman  with  a  helicoidal 
fracture  produced  by  rotation,  but  while  the  limb  was  bent.  Similar 
fractures  were  produced  on  the  dead  body  in  the  same  way  by 
rotation  of  the  bent  limb.  In  Mr  Miller's  cases  the  fractures  were 
all  transverse.  (&.)  Along  with  Dr  Alexander  Bruce  a  distended 
gall-bladder  obstructed  by  malignant  tumour  of  the  duodenum. 
This  specimen  was  from  the  body  of  a  woman  aged  52.     She  first 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    VIII.  5  B 


746  MEETINGS   OF   SOCIETIES.  [FEB. 

showed  symptoms  two  years  ago,  when  she  suffered  from  vomiting 
and  constipation  with  intermittent  attacks  of  diarrhoea,  and  liremor- 
rhage  from  the  bowel.  The  enlargement  of  the  gall-bladder  was 
apparent  ten  months  before  death,  and  jaundice  three  months. 
She  had  great  thirst  and  craving  for  food,  but  distinctly  and 
frequently  denied  having  pain.  It  was  thought  before  death  that 
the  obstruction  was  probably  caused  by  malignant  disease  of  the 
pancreas,  but  at  the  autopsy  this  was  found  to  be  healthy,  the 
duodenum  being  affected.  The  case  was  one  of  great  rarity. 
Murchison  in  his  work  referred  to  only  three  cases  in  which  a 
similar  condition  was  found,  but  in  them  the  pancreas  was  involved, 
and  Mr  W.  H.  Kesteven  had  recently  recorded  in  the  Lancet  a 
case  of  cancer  of  the  pancreas  with  biliary  obstruction.  A  cast  by 
Mr  Cathcart  showing  the  condition  of  the  parts  when  fresh  was 
also  shown. 

The  Vice-President  considered  the  fracture  shown  was  not  through 
the  epiphysis,  but  through  the  shaft  of  the  femur.  It  was  at  least 
an  inch  above  the  epiphysial  line. 

2.  Dr  Allan  Sym  showed  a  tumour  of  the  bladder  from  the 
body  of  a  woman  aged  73.  It  had  been  operated  on  by  scraping 
twice.  Dr  Angus  Macdonald  had  operated  first  some  years  ago, 
and  Dr  Croom  only  last  August.  Both  operations  were  followed 
by  great  hgemorrhage.  A  month  after  the  last  operation,  for 
persistent  haemorrhage  several  styptics  were  tried  unavailingly. 
The  only  one  that  was  partially  successful  was  a  decoction  of  the 
leaves  of  hamamelis.  The  greater  part  of  the  posterior  wall  and 
the  fundus  of  the  bladder  were  involved,  but  not  the  ureters  nor 
the  urethra.     The  tumour  was  a  rapidly  growing  carcinoma. 

The  Vice-President  said  this  was  the  third  case  in  which  he  had 
heard  of  death  following  the  scraping  of  villous  tumours  of  the 
bladder.  He  thought  some  means  might  be  adopted  of  draining 
the  bladder  after  the  operation,  and  preventing  the  accumulation 
of  urine  and  the  consequent  systole  and  diastole  of  the  bladder, 
which  did  not  allow  of  the  necessary  rest  to  the  part  after  opera- 
tion. 

3.  Dr  James  Ritchie  showed  a  cystic  kidney — the  left  one — 
which  after  injection  with  gelatine  and  carmine  weighed  41  oz. 
(the  right  one  27  oz.)  The  specimen  was  from  a  woman,  aged  45. 
Tumour  was  noticed  after  a  confinement  nine  years  ago,  but  in 
the  absence  of  symptoms  its  nature  was  not  diagnosed.  When 
symptoms  became  prominent  the  diagnosis  was  easy :  polyuria, 
thirst,  loss  of  flesh,  and  the  presence  of  a  large  nodular  tumour  in 
each  flank.  The  feeling  of  fluid  in  one  of  the  larger  cysts  was 
easily  felt  through  the  abdominal  wall.  The  patient  died  of 
uraemia  without  convulsions,  and  retained  consciousness  to  the  end. 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  747 

II.  Origixal  Communications. 
1.  Dr  Craig  read  a  paper  by  Dr  T.  Wyld  Fairman  of  Auckland 

on    THE   TREATMENT   OF    DIPHTHERIA    IN    CHILDREN    BY   ANTISEPTIC 

STEAM,  which  appears  at  page  724  of  this  Journal. 

The  Vice-President  expressed  his  sense  of  the  value  of  Dr  Pair- 
man's  paper.  He  did  not  quite  understand  if  the  child  was  com- 
pletely tented  in. 

I)r  Craig  said  he  believed  Dr  Pairman's  usual  plan  was  to  place 
a  large  umbrella  opened  out  at  the  head  of  the  child's  bed,  and  to 
put  a  sheet  over  this  extending  to  the  foot. 

Prof.  Simpson,  in  the  course  of  a  few  remarks,  pointed  out  that 
the  title  of  the  paper  was  somewhat  misleading.  It  was  not 
antiseptic  steam,  that  was  to  say  steam  containing  some  volatile 
antiseptic,  that  was  used,  but  ordinary  steam  and  sulphur  fumes. 
In  the  first  case  he  understood  it  was  steam  alone  that  was  used, 
and  this  did  well.  The  sulphur  fumes  were  introduced  into  the 
treatment  of  the  other  cases.  He  would  have  been  glad  had  there 
been  a  little  more  careful  analysis  of  the  various  elements  in  the 
treatment. 

Dr  P.  A.  Young  was  interested  to  hear  of  Dr  Pairman's  success 
in  the  treatment  of  cases  of  diphtheria  by  steam.  He  had  himself 
treated  cases  in  this  way  for  at  least  twelve  years.  He  had  been 
using  it  generally  for  some  time,  but  he  had  a  very  bad  case  in  a 
young  child,  and  found  that  it  received  the  greatest  benefit  by 
being  kept  in  an  atmosphere  of  steam  for  four  or  five  days,  after 
which  it  recovered.  He  was  satisfied  that  they  possessed  no 
remedy  so  efficacious.  Superadded  to  it  he  often  used  antiseptics. 
Some  time  after  having  this  case  he  read  an  article  by  a  French 
physician,  who  said  the  action  of  the  steam  was  to  produce  a  layer 
of  healthy  pus  cells  between  the  false  and  the  mucous  membranes. 
In  this  way  the  false  was  thrown  off  and  further  absorption  into 
the  system  prevented.  He  did  not  know  how  far  this  was  a 
correct  explanation  of  the  modus  operandi,  but  he  gave  it  for  what 
it  was  worth.  Whooping-cough,  where  there  was  bronchial  catarrh 
to  any  extent,  might  be  efficaciously  treated  in  the  same  way, 
various  antiseptics  being  added  to  the  steam. 

Dr  M'Bride  was  of  opinion  that  steaming  with  antiseptics  was 
not  likely  to  be  of  much  more  value  than  simple  steam,  itself  an 
old-established  and  efficient  remedy.  Strong  antiseptics  applied  in 
the  form  of  sprays  and  pigments  constantly  failed  in  the  treatment 
of  diphtheria.  It  was  hardly  to  be  expected  that  a  dilute  volatile 
antiseptic  would  succeed  in  such  cases. 

Dr  Thorn  (Crieff)  said  he  could  not  trust  to  volatile  antiseptics. 
He  found  steam  very  valuable  if  applied  before  the  disease  extended 
to  the  larynx.  When  this  occurred  he  had  been  uniformly  unsuc- 
cessful. He  frequently  used  as  a  pigment  a  strong  antiseptic 
containing  perchloride  of  iron  and  sulphurous  acid.     He  found  a 


748  MEETINGS   OF   SOCIETIES.  [FEB. 

pigment  of  boroglyceride  in  glycerine  very  beneficial  and  more 
pleasant  to  children.  Sulphur  was  a  very  old  remedy,  and  flowers 
of  sulphur  were  constantly  used  in  his  district. 

Mr  Cathcart  observed  that  in  the  discussion  there  was  no 
confirmation  of  a  statement  he  had  read  some  time  ago,  that 
steaming,  particularly  over- steaming,  did  harm.  He  was  of 
opinion  that  weak  volatile  antiseptics  constantly  applied  might 
prove  efficacious  where  the  stronger  antiseptic  applied  intermit- 
tently with  a  brush  failed.  While  much  was  to  be  said  for 
steaming,  it  was  not  to  be  supposed,  as  one  might  imagine  from 
what  had  been  said,  that  the  patient  only  required  to  be  steamed 
to  be  made  well.  Constitutional  treatment  was  also  necessary, 
but  many  cases  proved  fatal  in  spite  of  all  treatment.  One  remark 
made  in  the  paper  that  in  different  epidemics  the  fungus  seemed 
to  choose  different  sites  was,  he  thought,  an  argument  in  favour  of 
the  non-identity  of  croup  and  diphtheria. 

Dr  Wehster  desired  to  add  his  testimony  to  the  value  of  steam- 
ing in  these  cases.  He  was  somewhat  disappointed  with  the  paper, 
hoping  from  the  title  that  they  were  to  hear  of  some  new  and 
successful  antiseptics  from  the  Antipodes. 

Dr  Allan  Sym  said  he  had  lately  to  deal  with  an  epidemic  in 
his  district.  He  treated  his  cases  by  pigments  of  boroglyceride, 
and  also  gave  perchloride  of  iron  internally.  Having,  however, 
taken  the  disease  from  a  patient,  he  experienced  so  much  pain  in 
swallowing  that  he  had  given  up  internal  remedies,  and  simply 
painted  the  throat  with  the  boroglyceride,  being  quite  as  successful 
without  internal  treatment  as  with  it. 

Mr  Maxwell  Eoss  said  that  in  more  southerly  parts  of  New 
Zealand,  particularly  round  about  Dunedin,  the  treatment  of 
diphtheria  by  blue  gum  steam  was  exciting  some  interest,  and 
some  very  successful  results  were  claimed  for  it.  He  believed 
that  a  gentleman  had  gone  from  Dunedin  to  some  of  the  larger 
Australian  towns  to  demonstrate  its  value,  but  he  had  been  dis- 
appointed in  the  leaves  of  the  blue  gum  grown  in  Australia,  which 
he  did  not  find  give  such  good  results.  Dr  Sym,  he  understood, 
had  given  up  internal  administration  of  remedies  because  of.  the 
pain  in  swallowing.  He  did  not  think  pain  was  a  symptom  of 
diphtheria,  and  if  it  occurred,  considered  it  was  due  to  some 
accompanying  inflammation  such  as  tonsillitis.  He  thought  it 
would  be  a  mistake  to  give  up  internal  treatment,  and  seeing  that 
many  of  these  cases  died  of  cardiac  failure,  he  asked  if  any  member 
had  experience  of  digitalis  in  diphtheria. 

Dr  James  Ritchie  said  he  wished  Dr  Pairman  had  given  his 
experience  of  the  relative  merits  of  steam  and  of  the  antiseptic. 
The  speaker  used  steam  in  croup,  antiseptics  in  diphtheria.  But 
in  children  the  difficulties  connected  with  the  use  of  pigments  and 
sprays  were  so  great  that  some  efficient  method  to  replace  these 
was  very  desirable.     Dr  Pairman  had  recorded  certain  facts  and 


1889.]  MEDIGO-CIIIllUllGICAL   SOCIETY    OF   EDIJSBUliGH.  749 

made  certain  deductions  which  might  be  criticised,  but  Dr  Kitchie 
would  make  trial  of  antiseptic  steam.  The  speaker  never  used 
strong  caustics  in  this  disease.  He  found  pain  to  be  a  very  vari- 
able symptom,  and  he  believed  it  to  be  due  to  inflammation,  apart 
from  the  diphtheritic  process,  at  least  not  a  necessary  part  of  it. 
He  believed  that  the  disease  was  primarily  local  and  secondarily 
constitutional  from  poisoning  of  the  system  by  ptomaines.  Death 
from  cardiac  syncope  was  only  one  of  the  forms  of  post-diphtheritic 
paralysis. 

Mr  Miller  asked  Dr  Sym  if  he  had  any  experience  of  steaming, 
and  if  he  had  found  it  of  any  help  in  his  own  case  ? 

Dr  Sym  replied  that  it  was  not  used. 

Mr  Miller,  continuing,  said  he  had  long  wished  to  have  a  method 
of  treatment  devised  which  would  prevent  the  necessity  for 
tracheotomy.  No  treatment  had  hitherto  proved  satisfactory  in 
that  respect,  and  when  discussing  modes  of  treatment  which 
appeared  to  be  attended  with  success,  they  must  remember  that  in 
epidemics  of  any  kind  they  might  have  a  series  of  fatal  cases 
followed  by  a  long  run  of  successful  ones — recovering,  apparently, 
whatever  mode  of  treatment  was  adopted.  He  considered  more 
attention  should  be  paid  to  the  prophylaxis  of  diphtheria  than  was 
done  at  present.  An  epidemic  of  diphtheria  should  be  looked  upon 
as  a  disgrace  to  medicine  and  to  civilisation. 

Dr  Craig  was  very  pleased  that  the  paper  he  had  read  for 
Dr  Pairman  had  elicited  such  an  interesting  discussion.  Dr 
Pairman's  treatment  appeared  to  have  been  very  successful. 
They  had  a  very  volatile  antiseptic  in  sulphurous  acid,  which  he 
sent  into  the  atmosphere  by  burning  a  teaspoonful  of  sulphur 
every  hour.  His  father,  the  late  Dr  Pairman  of  Biggar,  long  ago 
practised  this  mode  of  treatment.  The  steaming  had  been  success- 
ful in  some  of  the  cases  in  which  the  disease  had  spread  into  the 
larynx,  and  certainly  no  harm  could  be  said  to  have  been  done  by 
it  to  any  of  his  patients.  Dr  Eoss  had  referred  to  the  difference 
found  in  the  eucalyptus  leaves  in  New  Zealand  and  Australia. 
This  was  not  an  nncommon  experience.  The  late  Sir  Eobert 
Christison  had  pointed  out  that  certain  umbelliferous  plants  were 
found  to  be  poisonous  when  grown  in  one  district  of  country,  but 
quite  harmless  when  grown  in  another.  He  should  ask  Dr  Pair- 
man  to  inquire  into  the  point  that  had  been  raised, — the  effect  of 
steam  alone,  and  steam  with  sulphur  fumes.  He  would,  however, 
like  to  point  out  that  there  might  be  a  difference  in  the  disease 
due  to  the  semi-tropical  climate  from  what  they  usually  found  in 
this  country. 

2.  Dr  M'Bride  read  his  clinical  notes  on  lipomata  of  the 
LARYNX,  which  appears  at  page  703  of  this  Journal. 

Mr  Cathcart  asked  if  the  term  laryngeal  was  strictly  applicable 
to  these  tumours.     It  seemed  to  him  that  the  first  at  any  rate 


750  MEETINGS    OF   SOCIETIES.  [fEB. 

grew  from  the  back  of  tlie  tongue  rather  than  the  larynx. 
Tumours  of  the  size  shown  .growing  into  the  larynx  must  have 
produced  severe  obstruction  to  respiration. 

Dr  M'Bride  said  he,  in  the  first  place,  pleaded  ])recedent  for 
calling  these  tumours  laryngeal,  and  in  the  second,  two  of  them 
grew  from  laryngeal  structures,  while  the  third,  although  growing 
from  the  sinus  pyriformis,  projected  into  the  larynx  and  covered 
one  arytenoid  cartilage.  Tliough  so  large  they  had  a  wonderful 
power  of  adapting  themselves  to  the  sinuosities  of  the  larynx,  so 
much  so  that  they  might  at  times  be  missed  even  by  those 
accustomed  to  make  laryngoscopic  examinations. 


OBSTETRICAL  SOCIETY  OF  EDINBURGH. 

SESSION   L. — MEETING   II. 
Wednesday,  \2th  December  1888. — Dr  Underbill,  President,  in  the  Chair. 

I.  Prof.  Simpson  showed  a  hydeogephalous  fcetus. 

II.  Dr  Matheson  showed  two  well-marked  examples  of  the 
anencephalous  fcetus.  The  history  of  the  labour  was  very  similar 
in  both  cases :  hydramnios  was  present,  the  base  of  the  cranium 
presented,  and  uterine  inertia  existed  from  the  first,  so  that  delivery 
had  to  be  effected  in  the  one  case  by  manual  assistance,  in  the 
other  by  the  use  of  the  forceps.  The  deformity  is  described  as 
being  caused  by  intrauterine  hydrocephalus,  which  is  so  excessive 
that  the  pressure  of  the  fluid  causes  the  brain  substance  and  cranial 
vault  to  atrophy  and  disappear ;  finally,  the  membranes  of  the 
brain  rupture,  the  fluid  escapes,  and  nothing  is  left  but  a  small 
mass  of  connective  tissue  covered  by  the  collapsed  membranes. 
In  both  foetuses  shown  a  similar  condition  affects  the  spinal 
column :  its  posterior  part  and  the  spinal  cord  are  absent,  while 
the  membranes  are  present.  Very  frequently  such  children  have 
other  deformities  and  defects  of  development.  Thus  in  the 
specimens  before  the  Society,  hare-lip,  cleft  palate,  club-foot,  and 
other  deformities  are  seen. 

III.  Dr  Milne  Murray  showed  a  placenta  with  velamentous 
INSEKTION  of  THE  COED.  The  cord  entered  the  membranes  about 
3  inches  from  the  margin,  and  from  this  point  three  large  branches 
pass  on  to  the  foetal  surface.  The  labour  was  normal  in  every 
way. 

IV.  Dr  Halliday  Croom  showed — 1.  Two  large  polycystic 
OVARIAN  TUMOURS  removed  from  the  same  patient.  The  first  was  so 
adherent  to  bowel,  and  the  pedicle  so  hard  and  thick,  that  it  was 
found  impossible  to  secure  otherwise  than  extra-peritoneally.     The 


1889.]  OBSTETKICAL   SOCIETY    OF    EDINBUKGH.  751 

second  was  easily  enough  removed  by  Staffordshire  knot.  From 
the  enormous  amount  of  ascites,  and  the  condition  of  the  peri- 
toneum as  well  as  the  extreme  vascularity  and  friability  of  the 
tumours,  they  were  at  the  time  of  removal  thought  to  be  malignant. 
Microscopic  examination  has  not  confirmed  this.  The  patient  is 
doing  well.  2.  Ovaries  and  tubes  from  a  case  of  acute  gonorrhceal 
salpingo-oophoritis.  The  patient  was  a  prostitute  from  the  Lock 
Hospital,  and  had  suffered  for  years ;  the  present  attack  was 
comparatively  recent.  The  tubes  were  thickened,  but  not  dilated. 
There  was  no  pus.  3.  A  case  of  well-marked  hydrosalpinx  ;  on 
removal  about  the  size  of  a  large  orange.  4.  Two  pairs  of 
appendages,  removed  in  two  cases  of  small  bleeding  fibroids. 
5.  A  simple  ovahian  tumour,  with  a  large  haematocele  of  ovary  on 
opposite  side. 

V.  Dr  Berry  Hart  read  his  contribution  to  the  pathology, 

SYMPTOMS,   AND    TREATMENT    OF    ADHERENT    PLACENTA,    whicll    will 

appear  in  a  future  number  of  this  Journal. 

Prof.  Simpson  had  listened  with  great  interest  to  the  admirable 
paper,  marked  by  the  careful  observation  and  ingenious  and 
original  reasoning  that  usually  characterized  Dr  Hart's  contribu- 
tion. He  would  suggest  that  the  designation  which  Dr  Hart  had 
applied  to  the  loose  structure  at  the  plane  of  separation  might  be 
modified,  as  the  term  "  trabecular"  had  already  been  years  ago 
applied  by  Winkler  and  others  to  the  expanded  layer  of  the 
placenta  intermediate  between  the  parietal  or  uterine  and  sub- 
chorionic  layers.  The  decidua  vera  was  usually  divided  into  a 
compact  and  spongy  layer ;  and  as  the  layer  referred  to  in  the 
paper  corresponded  to  the  deeper  layer  of  the  decidua,  it  might  be 
called  the  spongy  or  separation  layer.  The  divisions  of  adherent 
placenta  which  Dr  Hart  had  suggested  were  probably  correct  in 
the  main,  and  he  (Prof.  Simpson)  recognised  their  clinical  import- 
ance. Especially  interesting  and  important  were  the  observations 
made  in  one  of  the  cases  as  to  the  diminution  of  the  glandular 
spaces  and  the  thickening  of  the  interglandular  connective  tissue, 
which  prevented  the  normal  detachment  of  the  placenta.  It  would 
be  of  great  moment  to  make  further  observations  as  to  these  cases, 
as  Dr  Hart  has  said ;  but  happily  the  opportunity  of  making  such 
observations  on  the  placenta  in  situ  were  rare,  and  when  the 
placenta  had  been  removed  we  have  not  all  the  material  for  examina- 
tion, unless  a  layer  of  uterine  muscular  fibre  has  been  stripped  off 
with  it.  The  important  distinction  between  the  cases  of  partial 
separation,  where  in  one  group  the  detachment  had  occurred  lower 
down  and  in  another  higher,  was,  he  (Prof.  Simpson)  believed, 
founded  on  true  clinical  observation.  The  cases,  however,  where 
the  placenta  was  split  through  further  from  the  muscular  wall, 
between  the  uterine  and  trabecular  or  sinuous  layers,  must  be 
very  rare.     At   least  he  (Prof.   Simpson)  could   not  charge  his 


752  MEETINGS   01-'   SOCIETIES.  [FKB. 

memory  with  ever  having  seen  a  case  where  the  large  celled  or 
uterine  layer  was  left  adherent  to  the  muscular  wall,  and  when  it 
did  occur  it  would  only  be  likely  in  very  limited  areas.  He  would 
like  to  supplement  tlie  conditions  of  placental  adhesion  tabulated 
by  Dr  Hart,  by  the  addition  of  the  cases  where  the  configuration 
of  the  placenta  was  at  fault.  The  condition  he  (Prof.  Simpson) 
had  specially  in  view  was  the  morbidly  expanded  area  of  placental 
development.  The  placenta,  when  of  ordinary  dimensions,  has  a 
relatively  thick  border,  and  forms  a  mass  which  can  be  grasped  by 
the  uterus  for  its  expulsion  ;  but  where  the  placenta  was  of  unusual 
extent  it  was  fiat,  and  thinned  out  towards  the  margins,  and  was 
in  such  cases  very  apt  to  remain  adherent,  and  very  difficult  of 
separation  at  the  hand  of  the  practitioner. 

Dr  Halliday  Groom  thought  Dr  Hart  had  made  an  excellent 
grouping  of  the  varieties  of  accidental  luemorrhage,  and  he  believed 
that  they  were  in  the  main  correct.  His  own  experience  had  led 
him  to  regard  the  lower  separation  as  the  more  serious.  As  to  the 
practical  point,  he  had  not  found  any  special  difficulty  in  removing 
an  adherent  placenta  at  term.  With  due  antisepsis  and  under 
chloroform  it  was  neither  risky  nor  difficult.  The  trouble  he  had 
always  found  was  in  dealing  with  the  condition  in  early  pregnancy, 
where  from  the  firmness  or  thickness  of  the  abdominal  walls  it 
was  impossible  properly  to  depress  the  fundus  and  so  make  a  clear- 
ance of  the  retained  portion. 

The  President  stated  that  Dr  Hart's  paper  brought  before  them 
in  a  very  able  manner  an  important  practical  subject,  because  they 
all  knew  very  well  the  anxiety  which  was  caused  by  these  cases, 
and  the  dangers  which  frequently  attended  them.  He  would 
point  out,  by  way  of  criticism,  that  possibly  some  of  the  difference 
in  the  microscopical  appearances  between  line  of  attachment  of 
the  adherent  placenta  which  he  showed  them  to-day,  and  the 
normal  appearances  of  the  same  area,  might  be  due  to  the  fact 
that  the  case  he  showed  them  had  been  in  spirit  for  a  long  time — 
months  certainly,  possibly  years.  The  new  point  to  him  in  Dr 
Hart's  paper  was  the  fact  that  adherent  placentae  might  be  separated 
in  various  planes  of  the  maternal  portion  of  the  placenta.  This 
explained  a  case  he  had  seen  where  he  had  to  remove  the  placentae 
of  twins  at  the  seventh  month,  where  tlie  placenta  after  removal 
appeared  to  have  been  separated  at  the  line  of  junction  of  the 
maternal  and  foetal  part.  There  was  no  smooth  cellular  layer 
whatever  upon  its  surface.  He  agreed  there  was  much  danger  in 
partial  adherence  of  the  placenta,  and  he  had  seen  a  case  where  a 
small  piece  of  placenta,  situated  in  its  very  centre,  had  been 
adherent  and  had  been  left  behind  in  the  uterus.  Severe  baimor- 
rhage  went  on  until  this  piece,  about  the  size  of  a  walnut,  was 
removed. 

Dr  Milne  Murray  agreed  with  the  Fellows  who  had  already 
spoken  in  regard  to  the  value  of  the  paper  Dr  Hart  had  read.     He 


1889.]  OBSTETKICAL   SOCIETY   OF  EDINBURGH.  763 

wished  to  remark  on  one  point  of  practical  interest  in  the  manage- 
ment of  these  cases.  Dr  Hart  recommended  the  separation  of 
these  placentse  by  detaching  the  structure  from  below  upwards, 
Dr  Murray  thought  that  a  certain  advantage  was  to  be  gained  by 
reversing  this  process  and  commencing  the  separation  from  above 
downwards.  It  was  easier  to  remove  the  whole  structure  at  once 
by  this  method,  and,  further,  we  were  less  likely  to  miss  any 
detached  lobes  (placentae  succenturatae)  by  carrying  the  hand  to 
the  fundus  at  once,  and  thus  exploring  the  whole  uterus. 

Dr  Berry  Hart  thanked  the  Fellows  for  their  kind  reception  of 
his  paper.  Dr  Simpson's  criticism  of  the  term  trabecular  layer 
was  quite  a  valid  one;  he  used  it  as  equivalent  to  the  spongy 
layer.  Dr  Milne  Murray  urged  that  the  placenta  should  be 
separated  from  above  down ;  he  had  always  found  it  easier  to  do 
so  from  below  up. 

VI.  Dr  Owen  Mackness  read  a  paper  on  the  relative  weights  of 
THE  placenta  AND  CHILD,  which  appears  at  page  716  of  this 
Journal. 

Professor  Siinpson  thought  the  Society  and  profession  were 
much  indebted  to  Dr  Mackness  for  the  labour  he  had  taken  in 
compiling  this  paper.  There  were  so  many  elements  that  entered 
into  the  production  of  weight  of  the  secundines,  that  it  was  easy  to 
understand  that  there  might  be  all  the  want  of  correspondence 
that  Dr  Mackness  had  found  between  weight  of  child  and 
weight  of  placenta.  For  what  was  needed  was  that  there  should 
be  intercommunication  between  foetal  and  maternal  blood, 
more  or  less  free,  according  to  the  greater  or  less  size  of  the 
infant,  and  this  could  be  provided  for  apart  from  mere  mass  of 
the  placenta. 

VII.  The  Secretary  read  for  Dr  Leith  Napier  a  paper  on  the 

RELATIONSHIP   BETWEEN   NEURALGIA   AND   ABORTION,  wMch   appears 

at  page  707  of  this  Journal. 

Dr  Sinclair  believed  that  Dr  Napier's  paper  embraced  a  very  wide 
area.  Neuralgias  are  ascribed  by  him  to  (1),  Keflex  irritation  ;  and 
(2),  Changes  in  blood.  The  anaemic  and  hydrsemic  condition  of 
blood  daring  pregnancy  appears  to  be  quite  a  sufficient  cause  for 
the  neuralgic  pains  independent  of  any  reflex  causes.  If  the 
latter  had  much  to  do  with  their  production,  convulsive  move- 
ments would  be  more  probably  the  result  or  accompaniment,  and 
these  are  rare  during  the  early  months  of  pregnancy.  The  associa- 
tion between  neuralgia  and  abortion  was  of  much  interest,  although 
a  careful  perusal  of  the  paper  would  be  necessary  before  many 
remarks  or  criticisms  could  be  applied. 

The  President  said  that  Dr  Napier's  paper  was  a  thoughtful,  but, 
at  the  same  time,  a  very  theoretical  one.  He  quite  agreed  with 
Dr  Napier  that  the  ordinary  neuralgias  of  the  head  and  neck  may 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.   VIII.  5   C 


754  MEETINGS   OF   SOCIETIES.  [FEB. 

occur  very  commonly  without  any  interruption  of  pregnancy. 
But  he  thought  Dr  Napier  laid  far  too  much  stress  upon  the 
neuralgic  pains,  which,  after  all,  were  mere  accidental  accom- 
paniments, as  it  were,  and  not  sufficient  upon  the  constitutional 
states  which  underlay  them.  He  was  not  prepared  to  follow  Dr 
Napier  in  the  large  and  frequently  repeated  doses  of  quinine 
which  he  gave,  as  there  was  some  evidence  to  show  that  quinine 
occasionally  acted  as  an  ecbolic. 


ROYAL  MEDICAL  SOCIETY. 

Jan.  11. — E.  C.  Carter,  M.B.,  in  the  chair.  H.  H.  Litthjohn, 
M.B.,  showed  the  following  specimens : — (1.)  A  Preparation  of 
advanced  Catarrh  of  the  Stomach.  The  whole  surface  beneath  the 
mucous  membrane  was  covered  with  small  haemorrhages,  varying 
in  size  from  a  pin-point  to  a  pea.  (2.)  A  Kupture  of  the  Aorta.  A 
woman,  aged  75,  rose  and  took  a  hearty  breakfast,  shortly  after 
which  she  was  seized  with  a  fit  of  coughing,  sat  down  in  a  chair, 
and  died  almost  immediately.  On  post-mortem  examination  the 
aorta  was  found  ruptured  about  1  inch  above  the  valves.  Its  two 
inner  coats  were  ruptured  to  the  extent  of  an  inch ;  the  edges  of 
the  rent  were  irregular  like  a  tear ;  the  rupture  through  the  outer 
coat  was  at  a  point  half-way  round  the  circumference  of  the 
vessel  and  opposite  the  internal  rupture,  the  blood  having  dis- 
sected its  way  round.  The  heart  was  fatty,  and  the  aortic  valves 
calcareous.  There  was  no  dilatation  of  the  aorta.  (3.)  Heart, 
showing  great  thickening  of  the  aortic  walls  and  ulcerative  end- 
arteritis. (4.)  Kidney,  showing  effects  of  advanced  pyonephrosis. 
(5.)  An  Abortion  at  an  early  date,  with  Membranes  and  Embryo 
attached.     B.  J.  Pirie  read  a  dissertation  on  Jaundice. 

Jan.  19. — H.  H.  Littlejohn,  M.B.,  in  the  chair.  J.  R.  Ratdiffe, 
M.B.,  gave  a  microscopic  demonstration  of  some  recognised  varie- 
ties of  Micro-organisms  and  Fungi.  R.  Muir,  M.B.,  communicated 
a  case  of  intense  Ansemia  associated  with  Purpuric  Eruption  and 
a  tendency  to  Haemophilia,  occurring  in  a  boy  aged  6  years.  The 
history  was  that,  after  a  period  of  about  two  years,  during  which 
the  patient  became  gradually  pale  and  weak,  a  purpuric  eruption 
appeared  all  over  his  body.  This  occurred  about  four  months  ago, 
and  since  then  the  crops  of  spots  had  appeared  at  intervals,  fading 
away  after  a  time.  On  admission  profound  anaemia  was  found  to 
be  present.  The  red  corpuscles  were  about  1,200,000  in  number, 
while  the  other  corpuscular  elements  and  the  haemoglobin  were  even 
more  than  proportionately  diminished.  Bleeding  from  a  prick 
went  on  for  an  indefinite  time,  and  could  only  be  stopped  by  the 
persistent  application  of  styptics.  The  purpuric  spots  were  of 
fairly  typical   appearance,  being    red  or  deep  purple    in  colour, 


1889.]  ROYAL   MEDICAL   SOCIETY.  755 

round  or  oval  in  shape,  and  being  most  numerous  over  the  lower 
part  of  the  back  and  abdomen,  and  over  the  thighs.  Over  the  face 
and  hands  the  spots  were  very  few,  and  those  present  were  of 
minute  size.  The  spots  varied  in  size  from  that  of  a  pin's  head  to 
a  quarter  of  an  inch  in  diameter.  Nothing  abnormal  could  be 
detected  in  the  condition  of  any  of  the  viscera.  The  temperature 
ranged  between  99""  and  102°-2  F.  The  patient  was  only  a  week 
under  observation,  during  which  time  he  gradually  became  weaker. 
On  two  occasions  he  had  hsematemesis,  but  the  blood  vomited  was 
small  in  quantity.  He  died  a  few  days  after  removal  from  the 
Infirmary.  J.  Ritchie,  M.B.,  communicated  a  case  of  Tubercular 
Disease  of  the  Kidneys  and  Bladder.  The  patient,  a  woman,  was 
admitted  to  the  Infirmary  complaining  of  incontinence  of  urine, 
pain  on  making  water,  occasional  paroxysms  of  pain  in  the  region 
of  the  bladder,  and  hgematuria.  The  illness  had  begun  seven  years 
previously,  and  no  definite  cause  could  be  assigned.  The  symp- 
toms had  gradually  increased  in  severity,  though,  till  admission, 
patient  had  been  alDle  to  continue  at  work.  The  temperature  was 
normal.  The  pulse  was  irregular,  but  no  lesion  in  the  circulatory 
system  could  be  discovered.  The  bladder  was  found  to  be  con- 
tracted, and  per  vaginam  a  special  thickening  was  detected  in  its 
posterior  wall.  There  was  great  pain  on  pressing  the  bladder 
between  the  external  and  internal  hands.  The  uterus  seemed 
normal.  The  urine  contained  a  small  quantity  of  albumen  and  a 
large  amount  of  pus.  It  was  decided  to  dilate  the  urethra,  to  see 
whether  chronic  cystitis  were  alone  present  or  a  new  growth.  A 
general  thickening  of  the  whole  bladder  was  found,  especially  marked 
in  the  floor.  The  patient  was  relieved  by  the  operation,  but  on  the 
third  day  septicaemic  symptoms  supervened,  and  she  died  on  the 
tenth  day.  The  post-mortem  examination  showed  contraction  of 
the  bladder  to  the  size  of  a  bantam's  egg,  great  thickening  of  its 
walls,  dilatation  of  both  ureters,  and  tubercular  abscesses  in  both 
kidneys,  the  right  being  almost  entirely  destroyed.  The  generative 
organs  were  healthy  and  the  heart  normal.  One  lung  showed 
commencing  tubercle  at  the  apex. 


CARLISLE  MEDICAL  SOCIETY. 

SESSION    V. — MEETING    I. 
Thursday,  8th  November  1888. 

Dr  Douie  was  elected  Vice-President  in  place  of  Dr  Macphail, 
resigned,  and  in  the  absence  of  Dr  Macdougall,  the  President,  he 
took  the  chair. 

A  full  discussion  on  the  state  of  the  library  took  place,  and  a 
committee  was  appointed  to  make  better  arrangements  regarding  it. 

Several  new  members  were  elected. 


756  MEETINGS   OF    SOCIETIES.  [FEB. 

Dr  Ea&iodl  showed  two  cases  of  excision  of  the  wrist. 

Dr  Lockie  showed  a  case  of  LOCOMOTOR  ataxia  which  had  been 
shown  at  a  previous  meeting,  and  now  presented  the  rare  occur- 
rence of  localized  oedema. 

Dr  Haswell  showed  a  CAST  OF  A  LEG  WITH  A  SARCOMATOUS 
TUMOUR;  and 

Dr  Dotiie  showed  a  specimen  of  hydrocele  fluid  of  an  unusual 
nature. 

MEETING   IL 
Thxmday,  IZth  December  1888. — Dr  DouiE  in  the  Chair. 

Dr  Meikle  showed  cases  of  cerebro-spinal  sclerosis  and  infan- 
tile PARALYSIS. 

Dr  Lediard  read  a  short  and  interesting  paper  on  joint  scraping, 
and  one  or  two  members  asked  questions  and  made  remarks.  Dr 
Lediard  replied. 

Dr  Walcot  read  his  notes  of  a  case  of  strangulated  umbilical 
HERNIA,  which  was  operated  on  by  Dr  Maclaren,  and  had  done 
well. 

Drs  Lockie,  Lediard,  and  Maclaren  gave  their  experience  of 
Umbilical  Hernia. 

Dr  Meikle  showed  the  following  specimens : — CAST  OF  A  conical 
STUMP;  TUBERCULAR  DISEASE  OF  KIDNEY  J  INTUSSUSCEPTION  OF 
SMALL  INTESTINE. 


MEETING   III. 

Thursday,  IQth  January  1889. — Dr  Lockie  and  afterwards  Dr  DouiE 
in  the  Chair. 

Dr  Lediard  showed  a  case  of  ununited  fracture  of  THE  HUMERUS 
on  which  he  was  going  to  operate. 

Dr  Haswell  showed  a  case  of  syphilitic  disease  of  the  forearm. 

Dr  Norman  Walker  showed  a  case  of  TRADE  PALSY  occurring  in 
a  reeler  in  a  cotton  mill. 

Dr  Lockie  read  a  short  and  thoughtful  paper  on  some  anomalous 
CASES  OF  NEUROSAL  DISEASE. 

Dr  Norman  Walker  read  a  note  on  a  case  of  intussusception, 
and  Drs  Maclaren,  Lockie,  and  Lediard  made  remarks. 

Dr  Lediard  showed  a  fibroma  removed  from  the  groin  of  a  young 
woman;  also  round-celled  sarcoma  of  forearm;  osteo  sarcoma 
of  femur;  perforating  ulcer  of  stomach;  and  sarcoma  of 
scapula. 

Dr  Haswell  showed  some  urethral  calculi  and  a  necrosed 
lamina  of  a  dorsal  vertebra. 


1889.]  MONTHLY   KEPOKT   ON   THEllAPEUTICS.  757 


PERISCOPE. 

MONTHLY  REPORT  ON  THE  PROGRESS  OF  THERAPEUTICS. 

By  William  Craig,  M.D.,  F.R.S.E.,  Lecturer  on  Materia  Medica,  Edinburgh 
School  of  Medicine,  etc.,  etc. 

The  Eelative  Value  op  Opium,  Morphine,  and  Codeine  in 
Diabetes  Mellitus. — Professor  T.  R.  Fraser,  in  the  British  Medical 
Journal  for  I9tli  January,  has  a  valuable  communication  on  the 
above  subject.     He  says,  "  Since  Pavy's  recommendation  of  codeine 
as  a  remedy  having  advantages  over  opium  and  morpliine  in  the 
treatment  of  diabetes  mellitus,  codeine  has  been  much  used,  and 
has  even  to  a  large  extent  displaced  opium  and  morphine  in  the 
treatment  of  this  disease.     There  are,  at  the  same  time,  no  clear 
pharmacological  data  in  support  of  this  preference.     Indeed,  in  the 
data   are   not    even  such    as    to    suggest   it;    for    notwithstanding 
assertions  of  a  like  superiority  in  the  relief  of  various  symptoms  of 
other  diseases,  the  facts,  so  far  as  we  know  them,  seem  to  show 
that,  pharmacologically,  codeine  is  in  its  most  important  actions 
merely  a  weak  morphine.     In  regard  to  its  therapeutic  effects  in 
tliose  conditions  other  than  diabetes,  in  which  it  is  now  commonly 
used,  I  have  also  failed  to  obtain  any  evidence  that  it  acts  otherwise 
than  a  weak  morphine, — for  example,  in  the  relief  of  cough,  the 
production  of  sleep  or  the  removal  of  pain,  whether  in  the  abdomen 
or  elsewhere."     After  detailing  the  results  of  careful  experiments 
on  patients  treated  by  him  in  the  Royal  Infirmary  of  Edinburgh, 
Professor  Eraser  says  :  "  A  consideration  of  these  averages  seems  to 
show  that,  under  a  daily  administration  of  one  grain  of  hydro- 
chlorate  of  morphine,  the  quantity  of  fluids  drunk,  and  of  urine, 
urea,  and  sugar  voided,  was  rather  less  than  when  three  grains  of 
opium,  and  decidedly  less  than  when  fifteen  grains  of  codeine  were 
being  taken.     In  three  other  cases  in  which  I  have  instituted  a 
comparison  between  these  substances  in  diabetes  mellitus,  morphine 
also   showed   a   marked,   though   not  so   great,   superiority   over 
codeine.     So  far  as  I  know,  also,  the  favour  with  which  codeine 
is  regarded  in  this  disease  has  not  been  supported  by  any  observa- 
tions calculated  to  show  its  value  relating  to  opium  or  morphine 
so  clearly  as  in  the  cases  to  which  I  have  referred.     The  evidence, 
therefore,  seems  to  indicate  that  codeine  is  a  less  powerful  remedy 
in  diabetes  than  either  opium  or  morphine,  and  to  confirm  the  view 
that  in  its  therapeutic  value  it  acts  as  a  weak  or  diluted  morphine." 

Antipyrin  in  Acute  Articular  Rheumatism. — From  a  study 
of  the  results  obtained  from  the  employment  of  antipyrin  in  twelve 


758  PERISCOPE.  [FEB. 

cases  in  rlieumatism,  Professor  P.  de  Tullio  {Bulletin  Gdniral  de 
Therapeutique,  15th  September  1888)  draws  the  following  con- 
clusions : — 1.  Antipyrin,  administered  in  doses  of  1\  grains  every 
hour  for  eight  hours,  increases  tiie  severity  of  the  pains  in  both 
acute  and  chronic  rheumatism,  and  leads  to  the  implication  of  other 
articulations.  This  latter  result,  according  to  the  author,  is  to  be 
explained  by  the  fact  that  antipyrin  causes  abundant  sweats,  thus 
predisposing  to  the  extension  of  the  disease  to  other  joints.  2.  In 
acute  articular  rheumatism  during  the  administration  of  this  remedy 
in  eight  cases  serous  pericarditis  developed  in  four.  In  four  other 
cases  endo-pericarditis  developed,  with  subsequent  affection  of  the 
mitral  valves.  3.  In  one  case  of  clironic  articular  rheumatism 
transient  albuminuria  was  produced,  which  ceased  as  soon  as 
administration  of  antipyrin  was  suspended.  If  Tullio's  results  are 
accepted,  they  must  necessarily  do  away  with  the  teachings  of 
Frankel,  Berhim,  Masins,  Sde,  Clement,  Dujardin  Beaumetz,  and 
others,  who  have  claimed  that  antipyrin  is  a  specific  for  acute 
articular  rheumatism,  and  that  at  the  same  time  it  prevents  the 
cardiac  complications  so  common  in  this  affection. — Therapeutic 
Gazette^  December  1888. 

The  Use  of  Antipyrin  in  the  Nasal  Passages. — F.  Whitehill 
Hinkel,  M.D.,  draws  the  following  conclusions  from  the  results 
obtained  by  the  use  of  antipyrin  upon  the  nasal  passages  {New  York 
Medical  Journal^  20th  October  1888) : — 1.  A  solution  of  antipyrin 
possesses  hasmostatic  properties  when  sprayed  into  the  nose,  though 
not  superior  to  cocaine.  2.  Antipyrin  in  about  four  per  cent,  solu- 
tion may  be  used  upon  the  nasal  mucous  membrane  with  temporary 
relief  to  occlusion  from  engorgement  of  the  turbinates,  and  witii 
sedative  effects  upon  irritable  states.  3.  It  is  most  effective  where 
the  element  of  irritation  exceeds  that  of  inflammation.  4.  It 
presents  an  advantage  over  cocaine  in  not  producing  local  numbness 
and  dryness,  and  in  the  absence  of  the  general  stimulating  properties 
of  cocaine  causing  sleeplessness,  headache,  etc.  In  cases  such  as 
hay  fever,  where  an  agent  of  relief  is  used  for  long  periods,  anti- 
pyrin as  a  nasal  spray  is  less  likely  than  cocaine  to  produce 
constitutional  disturbance  or  to  lead  to  a  "  habit."  5.  Antipyrin 
presents  the  disadvantage  of  causing  more  or  less  severe  smarting, 
and  of  being  unequal  to  the  relief  of  severe  inflammation  or  extreme 
occlusion  of  the  nares.  6.  Its  antiseptic  and  stimulant  properties 
will  probably  make  it  serviceable  as  an  application  to  fresh  wounds 
and  to  granulations  and  ulcerations  in  the  nasal  chambers.  7. 
Combined  with  cocaine,  it  increases  the  local  action  of  the  latter, 
enabling  it  to  be  used  in  weaker  solution. — Therapeutic  Gazette, 
December  1888. 

Amylene  Hydrate. — Dr  Jumon  {La  France  Medicate)  recom- 
mends amylene  hydrate  in  3   gramme  doses  as  a  hypnotic.     Its 


1889.]  MONTHLY    REPORT    ON   THERAPEUTICS.  759 

action  is  stronger  than  tliat  of  paraldehyde,  but  less  so  than  tliat  of 
chloral.  It  first  produces  a  period  of  excitement,  which  is  quickly- 
followed  by  sleep.  He  employs  the  drug  in  diseases  of  the  ali- 
mentary, circulatory,  and  nervous  systems,  and  quotes  the  good 
results  obtained  from  its  use  by  Dr  Gurther  of  Konigsberg,  and 
Dr  Dietz  of  Leipzig.  Amylene  hydrate  is  soluble  in  eight  parts 
of  water. — Dublin  Medical  Journal,  December  1888. 

SuLPHONAL. — Sulphonal  still  continues  to  attract  considerable 
attention,  and  its  use  is  becoming  very  general.  Dr  Julius 
Schwalbe,  in  the  Centralhlatt  filr  die  Gesammte  Therapie  for  Octo- 
ber 1888,  refers  to  fifty  cases  of  the  most  varied  affections  in  which 
sulphonal  was  employed.  In  Q^  per  cent,  of  these  sleep  was  pro- 
duced within  three  hours.  In  the  nervous  cases  this  action  was 
even  more  pronounced,  in  90  per  cent,  of  them  the  indications  being 
successfully  fulfilled.  Dr  Schwalbe  consequently  recommends 
sulphonal  as  a  good  hypnotic,  especially  in  cases  of  nervous 
insomnia,  in  doses  of  from  15  to  30  grains.  Where  insomnia  is 
the  result  of  some  direct  organic  distress,  its  action  is  more  or  less 
uncertain.  He  has  found  that,  on  account  of  its  freedom  from  odour 
and  taste,  sulphonal  is  readily  taken,  and  that  it  does  not  affect 
either  the  temperature,  pulse,  or  respiration,  and  is,  consequently, 
greatly  to  be  preferred  to  morphine  or  chloral.  In  febrile  affections, 
and  in  all  cases  where  there  is  heart  weakness,  it  is  to  be  guarded 
against.  It  is  especially  suited  for  children,  and  the  insignificant 
disturbances  which  it  occasionally  produces  are  not  of  sufficient 
importance  to  be  counter-indications  for  its  employment.  M. 
Matthes  has  also  employed  sulphonal  in  twenty-seven  cases  in 
Professor  von  Ziemssen's  clinic,  Munich  {Centralhlatt  fiir  Klinische 
Medicin,  6th  October  1888),  his  report  being  accompanied  by  an 
analysis  of  the  pulse-curves  obtained  through  the  use  of  the  sphyg- 
mograph.  He  likewise  confirms  the  favourable  position  which  the 
drug  has  obtained,  and  believes  that  it  is  to  be  preferred  to  all 
other  hypnotics,  recommending,  however,  that  the  drug  should  be 
given  at  least  an  hour  before  it  is  desired  that  sleep  shall  be  pro- 
duced. He  also  thinks  that  when  neuralgia  or  cough  are  the 
occasion  of  insomnia,  that  its  result  is  unreliable,  although  he  refers 
to  several  cases  of  neuralgia  in  which  its  employment  produced 
relief  No  effect  was  produced  upon  the  pulse-curve,  even  after  the 
administration  of  60  to  75  grains. — Therapeutic  Gazette,  December 
1888. 

Cocaine  in  the  Treatment  of  Ulcers. — Dr  Nason,  in  the 
British  Medical  Journal  for  5th  January,  recommends  the  applica- 
tion of  a  2  per  cent,  solution  of  cocaine  to  ulcers  before  being 
dressed.     This,  he  says,  saves  pain. 


760  PERISCOPE.  [FEB, 


OCCASIONAL  PERISCOPE  OF  DERMATOLOGY. 

By  W.  Allan  Jamieson,  M.D.,  F.R.C.P.,  Extra  Physician  for  Diseases  of 
the  Skin,  Edinburgh  Royal  Infirmary ;  Lecturer  on  Diseases  of  the  Skin, 
Edinburgh  School  of  Medicine. 

The  Treatment  of  Hyperidhosis. — In  reply  to  a  correspondent 
who  had  failed  to  relieve  excessive  perspiration  of  the  liands  in  a 
girl  of  seventeen,  which  had  existed  since  birth,  by  any  means, 
indudinoj  unguentum  diachyli,  Unna  says,  "  In  my  opinion  the 
abnormality  from  wiiich  your  patient  suffers  is  not  occasioned  by 
disease  of  the  sweat  glands,  nor  by  disorder  of  the  nerves  which 
supply  these  glands,  since  the  coil  furnishes  only  the  fatty  part  of 
the  perspiration ;  but  I  attribute  it  much  more  to  an  abnormal 
condition  of  the  entire  filtration  tissue,  which  has  to  do  with  the 
conveyance  of  the  cutaneous  fluids  to  the  surface.  This  is  com- 
posed of  the  capillaries  and  connective  tissue  of  the  papillary  body, 
of  the  lymph  canals  of  the  epidermis,  and  the  sweat  pores.  Where 
the  increased  permeability  in  the  path  of  filtration  lies  cannot  be 
positively  stated,  and  may  differ  in  individual  instances,  but  this 
does  not  preclude,  indeed  it  is  physiologically  a  necessity,  that 
increased  watery  transudation  from  the  sweet  pores  promotes  the 
secretion  of  the  fatty  product  of  the  gland  through  the  same  aper- 
tures. Accordingly,  tlie  secretion  of  the  palm  will  be  partly  watery, 
partly  fatty,  when  in  greater  quantity  more  watery.  The  capil- 
lary bloodvessels  form,  as  regards  their  condition,  important  factors 
in  the  separation  of  this  secretion,  and  according  as  these  are  dilated 
or  contracted  I  distinguish  the  warm  and  the  cold  moist  hand.  In 
the  warm  moist  hand  the  rapid  refrigeration,  produced  by  tiie 
evaporation  of  the  secretion  which  is  present  in  excess,  is  over- 
compensated  by  the  heat  of  the  quickly  circulating  blood.  In  the 
cold,  the  abnormally  great  watery  evaporation  leads,  if  uninterfered 
with,  to  excessive  chilling  of  the  extremities.  Most  of  the  simple 
so-called  cold  feet  are  nothing  more  than  examples  of  feeble  hyperi- 
drosis  with  defective  circulation  of  the  skin  of  the  extremities. 
The  treatment  of  cold  sweating  of  the  hands  or  feet  consists  solely 
in  regulating  the  relation  between  the  filling  of  the  arterial  vessels 
and  the  unnaturally  great  evaporation  from  the  skin.  It  is 
advisable  to  administer  hot  pediluvia  before  retiring  to  bed,  to 
which  substances  which  stimulate  the  skin  may  be  added,  such  as 
spirit  of  camphor,  mustard,  vinegar,  etc.  These  are  followed,  after 
drying  the  hands  or  feet,  by  the  application  of  an  ointment  calcu- 
lated to  cause  hypersemia,  as  I^  01.  terebinth,  ichthyol,  aa  5'0,  ung. 
zinci,  100.  In  the  morning  conversely,  with  ablutions,  friction  with 
ice-cold  water  can  be  combined,  since  after  this  time  the  extremities 
continue  in  active  movement.  But  these  cold  frictions  must  be 
persisted  in  till  hyperaemia  and  distinct  warming  of  the  extremities 
is  brought  about ;  the  inside  of  the  stockings  is  then  to  be  dusted 


18b9.]  PEKISCOPE   OF   DERMATOLOGY.  761 

with  a  powder  containing  mustard.  With  this  treatment  of  the 
cold  sweating  feet  by  means  of  rubefacients,  measures  can  be 
suitably  combined  which  occasion  shrinking  of  the  epidermis  and 
narrowing  of  tlie  pores  of  the  cutaneous  filters.  For  this  purpose 
I  recommend  before  everything  for  use  by  day  ichthyol,  in  oint- 
ment, soap,  or  spirit  solution.  The  treatment  of  the  warm  perspir- 
ing feet  and  hands  depends  on  producing  a  simultaneous  contraction 
of  the  calibre  of  the  arterial  vessels  on  the  one  hand,  and  of  the 
filtration  pores  for  the  cutaneous  transpiration  on  the  other.  For 
both  ends  I  again  recommend  ichthyol,  but  without  the  employ- 
ment of  increased  warmth  at  night  and  greater  cold  in  the  morning, 
for  purposes  of  stimulation.  Consequently,  at  night  luke-warm 
pediluvia  without  adjuncts  are  to  be  used,  inunction  with  simple 
ichthyol  ointment, — ^  Ichthyol,  aq.  aa  5"0,  lanolin,  20'0  ;  stockings 
to  be  woi'n.  In  the  morning  ablution  with  luke-warm  water  and 
over-fatty  ichthyol  soap  and  subsequent  drying,  so  as  to  leave 
some  of  the  latiier  on  the  feet  and  hands.  In  contrast  to  acid 
baths,  alkaline  ones  are  suited  in  this  instance  to  lessen  arterial 
fluction.  Still  I  do  not  recommend  such,  for  they  soften  the 
epidermis  too  much.  It  must  further  be  noticed  that  tannic  acid, 
used  by  many,  cannot  be  expected  to  produce  any  tanning  effect  so 
long  as  the  epidermis  is  entire,  since  the  horny  layer  does  not  admit 
of  being  tanned  as  the  cutis  does.  Tannic  acid,  as  an  acid,  is  to  be 
condemned  accordingly  in  this  affection  like  other  acids." — Monat- 
scheftefilr  praktische  Dermatologie,  No.  15,  1888. 

On  Pastes. — It  is  admitted  on  all  liands  that,  among  the  numer- 
ous advances  which  have  been  made  in  the  therapeutics  of  skin 
diseases  during  the  last  ten  years,  the  introduction  of  pastes,  espe- 
cially as  regards  the  treatment  of  eczema,  constitutes  one  of  the 
chief.  Lassar's  well-known  formula,  consisting  of  two  parts  of 
vaseline  and  one  each  of  starch  and  oxide  of  zinc,  with  2  per  cent, 
of  salicylic  acid,  is  not,  however,  the  sole  though  the  best  known, 
for  Unna  has  simplified  the  composition  by  showing  that  an  excel- 
lent paste  can  be  compounded  by  adding  a  small  proportion  of  silica 
to  ordinary  oxide  of  zinc  ointment.  Pastes  have  the  advantage  over 
ointments  in  two  directions.  One  that  while  the  treatment  by  fatty 
substances  is  maintained,  the  secretions  and  excretions  of  the  dis- 
eased skin  are  absorbed.  A  purely  fatty  vehicle  dams  up  the  watery 
secretion,  while  the  oily,  if  not  checked,  is  at  least  not  taken  up. 
Another  is  that  pastes,  when  applied,  leave  a  firm,  powdery  residuum 
on  the  surface,  much  pleasanter  than  an  oily  layer,  and  which,  in 
addition,  fixes  some  of  the  remedy,  instead  of  permitting  it  to  be 
easily  rubbed  off  like  an  ointment.  Dr  Gruendler  of  Hambm-g  has 
experimented  on  the  absorptive  power  of  various  indifferent  sub- 
stances, innocuous  powders,  which  may  be  used  to  form  pastes. 
Of  those  tried,  carbonate  of  magnesia  possessed  the  highest  capacity 
for  absorption,  yet,  from  being  deficient  in  body,  it  does  not  make 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    VIII.  6   D 


762  PEUISCOPE.  [FEB. 

a  good  paste.  He  recommends  it,  however,  as  an  addition  to  pastes 
otherwise  compounded,  to  increase  tlieir  absorptive  capacity,  in  the 
proportion  of"  from  10  to  20  per  cent.,  or  alone,  or  with  oxide  of  zinc 
as  a  dusting  powder.  The  addition  of  one  of  the  silicious  earths,  in 
the  proportion  of  about  10  per  cent,  to  ointments,  converts  them 
into  useful  pastes.  Should  it  be  the  object  of  the  paste  to  form 
such  a  dry  covering  on  the  skin  that  the  fatty  ingredient  and  com- 
bined drugs  are  to  be  taken  up  by  the  epidermis,  the  fatty  material 
must  be  one  of  those  most  readily  absorbed.  In  general,  then, 
animal  fats,  lard,  suet,  lanolin ;  next  to  these,  vegetable  fats ;  and 
last,  those  substances  which  resemble  fats,  as  vaseline  and  glycerine. 
— Moimtshefte  filr  praktische  Dermatologie,  No.  20,  1888. 

Pemphigus,  with  Milium  in  Cicatrices,  and  Arsenical 
Pigmentation. — Dr  Handford  of  Nottingham  relates  a  remarkable 
instance  of  pemphigus  in  which  many  of  the  bullae  were  arranged 
symmetrically,  came  out  for  a  long  period  in  successive  crops,  left 
cicatrices,  and  in  which  arsenic  did  not  only  do  no  good  but  led  to 
extensive  pigmentation.  The  patient  was  a  girl  aged  13,  and  there 
was  no  history  of  nervous  affections  or  of  syphilis.  In  the  scars 
numerous  white  millet  seed-like  bodies  formed,  apparently  due  to 
an  undue  proliferation  of  the  epidermis.  The  eruption  of  the  bullae 
was  accompanied  on  several  occasions  by  marked  rise  of  tempera- 
ture. He  failed  to  find  organisms  in  the  clear  fluid  from  the  bullae, 
nor  was  there  any  definite  evidence  of  implication  of  the  peripheral 
nerves  as  shown  by  alteration  in  the  cutaneous  sensibility,  or  affec- 
tion of  the  reflexes.  The  pigmentation  caused  by  the  prolonged 
use  of  arsenic  chiefly  affected  the  abdomen,  lower  part  of  the  chest, 
lumbar  region  of  the  back,  axillae,  groins,  and  inner  side  of  the 
thighs;  the  surface  was  sometimes  rough  and  branny,  sometimes 
smooth  and  moist.  Quinine  and  iron  proved  valuable,  while 
arsenic  did  not  appear  to  produce  any  beneflcial  effect  on  the  pem- 
phigus in  the  three  cases  which  he  records.  Two  admirable 
chromo-lithographs  illustrate  this  paper. —  Clinical  Society^ s  Trans- 
actions, 1887-88. 

Dermatological  Notes. — From  some  interesting  observations 
of  Dr  G.  T.  Elliot  we  have  extracted  the  following  : — 

1.  Acute  Multiple  Symmetrical  Gangrene. — A  muscular  German 
accustomed  to  work,  aged  23,  carried  on  the  4th  December  a  very 
heavy  and  unwieldy  object  downstairs,  and  again  exerted  himself 
long  and  severely  two  days  later.  Oji  7th  December  three  or  four 
spots  came  out  over  the  acetabula,  dry,  circular,  grayish-black,  and 
bounded  by  a  slightly  elevated  red  border,  unaccompanied  by  any 
subjective  sensations.  On  the  following  day  some  more  spots  ap- 
peared, and  the  earlier  ones  increased  in  size.  The  destruction  of 
tissue  by  the  eschars  extended  to  the  subcutaneous  connective 
tissue  in  the  case  of  the  larger,  and  the  skin  for  some  distance 
round  was  anaesthetic.     Pressure  over  the  spinous  processes  of  the 


1880.]  PERISCOPE   OF   DEUMATOLOGY.  763 

last  lumbar  vertebra  and  over  the  upper  portion  of  the  sacrum 
induced  pain.  Cicatrization  occurred  in  about  three  weeks  under 
antiseptic  treatment,  and  counter-irritation  over  the  spinal  cord. 
Elliot  at  first  regarded  the  case  as  one  of  herpes  zoster  gangrsenosus, 
but  on  further  consideration  was  led  to  rank  it  as  one  of  the  class 
of  cases  in  which  symmetrical  gangrene  has  followed  severe,  pro- 
tracted, and  excessive  exertion.  The  neurotic  nature  of  the  case 
seems  evident,  as  tiie  lesions  were  distributed  in  the  course  of  the 
gluteal  nerves,  while  the  anaesthesia  was  marked,  and  there  was 
tenderness  on  pressure  over  the  vertebrae.  There  w^as  in  this 
instance  neither  diabetes  nor  Bright's  disease.  Raynaud's  disease 
can  be  recognised  by  its  chronicity,  its  localization  primarily  on 
the  phalanges  of  the  fingers  and  toes,  the  intense  pain  which 
accompanies  its  development,  and  tlie  severe  vasomotor  disturb- 
ances preceding  if,  and  shown  by  local  ischaemia,  local  cyanosis, 
and  local  redness. 

2.  Relapsing  Double  Zoster. — The  patient,  a  German,  aged  39, 
had  had  syphilis  five  years  before,  and  had  also  suffered  from  inter- 
mittent fever.  The  zoster  first  came  out  over  a  portion  of  the  skin 
supplied  by  the  posterior  branches  of  the  last  four  cervical  nerves 
on  both  sides,  and  the  cervical  plexus.  Three  months  after,  he  had 
a  second  attack  in  the  same  situation.  On  both  occasions  he  had 
taken  quinine  shortly  before,  to  relieve  the  intermittent  fever. 
Elliot  recommends  the  use  of  Paquelin's  cautery  at  a  red  heat  to 
relieve  the  neuralgic  pains  in  zoster.  The  skin  over  the  origin  of 
the  nerves  is  superficially  cauterized,  but  not  so  deeply  as  to  pro- 
duce scarring.  This  method  of  treatment,  first  suggested  by  Dr 
Halstead,  has  never,  in  his  experience,  failed  to  relieve  or  entirely 
remove  the  pain. 

3.  Bullous  Eruption  produced  by  Quinine. — While  the  most 
frequent  eruption  caused  by  quinine  is  an  urticarial  one,  the  bullous 
is  the  rarest,  only  five  or  six  cases  having  been  recorded.  In  the 
case  he  cites,  the  bullae,  preceded  by  an  erythematous  rash,  appeared 
on  three  different  occasions  after  doses  of  five  grains  of  quinine. 
An  eruption  came  on  within  an  hour,  and  affected,  among  other 
situations,  the  wrists,  feet,  lips,  tongue,  and  roof  of  mouth  ;  and  some 
fresh  blebs  came  out  three  days  after  the  quinine  had  been  taken. 

4.  Lichen  Ruber  Actiminatus. — In  this  case  the  acuminati 
papules  were  most  numerous,  but  with  them  occurred  also  the 
flat  ones.  The  acuminate  were  arranged  in  diffuse  patches,  for  the 
most  part  composed  of  small  conical  papules,  the  size  of  a  pin's  head, 
which  had  developed  round  a  hair  follicle,  and  bearing  small  scales 
of  epidermis.  Elliot  confirms  the  value  of  arsenic,  but  he  speaks 
of  the  external  treatment,  which  Unna  so  strongly  praises,  in  terms 
of  approval.  This  consists  of  the  use  of  perchloride  of  mercury 
and  carbolic  acid  in  combination  with  unguentum  diachyli.  From 
2  grains  of  the  perchloride  up  even  to  15  may  be  employed  ;  of 
the  carbolic  acid  from  2  to  5  per  cent.     He  has  applied  this  oiiit- 


7G4  PERISCOPIi  [FEB. 

merit  locally,  and  to  the  exclusion  of  all  other  treatment,  in  many- 
cases  of  liclien  ruber,  and  has  not  found  it  to  fail  to  remove  the 
disease  rapidly  and  effectually.  Nor  does  tliere  seem  to  be  any 
danger  of  mercurial  absorption.  He  instances  one  case  where  it 
was  used  for  six  weeks  to  the  entire  surface  twice  daily,  being  only 
discontinued  when  the  disease  was  cured. — Journal  of  Cutaneous  and 
Genito- Urinary  Diseases,  September  1888. 

From  an  interesting  letter  giving  an  account  of  a  visit  to  the 
clinique  of  Dr  Henry  Leloir  at  Lille,  contributed  by  Dr  Unna,  we 
extract  the  following: — The  great  number  of  patients  affected  with 
lupus  was  remarkable.  The  northern  districts  of  France,  like  the 
corresponding  part  of  the  northern  portion  of  Germany,  the  province 
of  Hanover,  appear  to  be  peculiarly  rich  in  cases  of  lupus.  Most 
interesting  was  that  of  a  young  man,  over  whose  body  was  scattered 
120  isolated  patches  of  lupus,  leaving  out  of  consideration  the 
scars  of  tiiose  which  had  healed.  A  girl  who  had  also  lupus  of  the 
face  and  throat  exhibited  the  sclerotic  form  of  lupus  of  the  tongue, 
new  to  Unna.  He  saw  a  case  of  warty  tuberculosis  of  the  skin  on 
the  back  of  the  hand,  which  had  been  treated  satisfactorily  with 
ichthyol  alone.  Leloir  commonly  treats  lupus  either  as  Besnier  with 
the  galvano-cautery,  or  with  salicylic  plaster  muslin  as  follows:  — 
He  applies  for  two  or  three  days  at  first  the  salicylic  plaster  muslin, 
then  gently  scrapes  the  surface  with  the  sharp  spoon,  and  paints 
it  with  iodoform  ether.  For  ten  days  the  part  is  treated  with 
compresses  renewed  thrice  a  day,  moistened  with  the  undernoted 
lotion : — 

^     Hyd.  perchlorid.,         ...  1*0 

Glycerine,       ....  300-0 

Sp.  vini  rect.,               .             .             .  400*0 

Aquse,             ....  100-0 

Finally,  mercurial  plaster  muslin  is  applied.  Leloir  combines  scari- 
fications with  this  latter  plaster  muslin  to  improve  the  cicatrices. 
A  novelty  was  the  treatment  of  herpes  zoster,  labialis,  etc.  The 
patches  of  eruption  were  covered  with  compresses  o^iXio,  Eau  de  Botot, 
so  much  used  in  France  as  an  application  to  the  gums.  Under 
these  the  vesicles  dry  up  very  rapidly. — Monatshefte  fur  praktische 
Dermatologie,  No.  19,  1888. 

Treatment  of  Minute  Nodules  of  Lupus  after  the  Mass 
OF  Deposit  has  been  got  rid  of. — Unna  bores  out  each  nodule 
with  a  10  per  cent,  sublimate  point,  then  dresses  the  part  till  healed 
with  an  ointment  suggested  by  Dr  Brooke. 

5L     Acid  salicylic,  .  .  .  20-0 

Creasoti,        .  .  .  .  400 

Ung.  simp.,  ....  40-0 

— Monatshefte  fur  praktiscke  Dermatologie,  No.  19,  1888. 


I 


1889.]  PERISCOPE   OF   DEEMATOLOGY.  765 

Inoculated  Tuberculosis. — Dr  von  Diihring  observes  that  if 
a  case  of  inoculated  tuberculosis  is  to  be  accepted,  certain  postulates 
must  be  complied  with.  There  must  have  existed  in  the  system 
no  previous  source  of  tuberculosis ;  that  there  must  have  been  the 
implantation  of  bacilli  in  a  wound ;  and  that  the  tuberculosis 
developed  from  the  point  of  inoculation.  A  girl  of  14,  of  a  family 
free  from  a  tuberculous  history,  removed  the  earrings  from  the  ears 
of  an  intimate  friend  shortly  after  her  death  of  phthisis,  and  imme- 
diately placed  them  in  her  own.  The  lobes  became  raw  and  dis- 
charged, and  the  sores  refused  to  heal.  Not  long  after  an  ulcer 
formed  on  the  neck,  and  the  girl  wasted  and  commene 'd  to  cough. 
The  granulations  removed  from  the  ulcer  on  the  neck  and  the 
sputum  showed  tubercle  bacilli,  and  the  progress  of  the  ca.«;e  has 
been  that  of  rapid  phthisis. — Monatshefte  filr praktische  Dermatologie, 
No.  22,  1888. 


P<iXt  :irim 


MEDICAL    NEWS. 


THE  JUBILEE  OF  PROFESSOR  BONDERS. 

Translated  from  the  Weekblnd  van  het  Nederlandsch  Tijdschrift  voor  Geneeskunde, 
2n(l  June  1888,  by  John  Boyd,  M.D.,  Slamannan. 

On  the  27th  May,  the  day  on  which,  seventy  years  ago  at 
Tilberg,  Professor  F.  C.  Bonders  first  saw  the  light,  the  course  of 
the  public  honour-celebration  of  the  jubilee  was  commenced  by  a 
chorus  of  the  students,  "  zangvoreeniging,"  when  the  Latin  lyric, 
"  Nunc  Cantus  resonat,"  prepared  by  Heer  Montijn,  was  sung  by 
way  of  Gaudeamus.  The  Professor  was  deeply  touched  by  this 
unexpected  homage,  and  in  his  address  to  the  singers  expressing 
his  gratitude,  stating  that  though  this  was  the  last  day  of  his 
professorate,  the  students  had  shown  that  they  did  not  wish  the 
tjond  of  connexion  between  him  and  them  to  be  dissolved.  Farther 
on  in  the  day  there  came  relatives,  friends,  and  adherents,  and 
various  deputations,  all  bringing  their  jubilee  homages,  besides 
curators  of  the  University,  trustees  of  the  Eye  Hospital  for  the 
Poor;  the  Academical  Senate,  the  Medical  Faculty,  represented  by 
the  addresses  of  the  Ileeren  Homer,  Van  Sherpenzeel,  Lamers, 
and  Van  Goudoever ;  while  Heer  van  Berwerden  presented  to  the 
Professor  an  extraordinary  number  of  the  Studentenhlad  Minerva. 

The  28th  May  was  the  day  fixed  upon  by  the  Committee  which 
had  united  to  invite  Professor  Donders,  as  a  worthy  honour-testi- 
monial, to  the  installation  of  an  institution  whereby  the  name  of 
the  jubilee  shall  permanently  remain.  Tiie  presentation  took  place 
in  the  grand  Concert-zaal  van  Tivoli,  adorned  for  this  occasion 
tastefully  with  plants  and  flowers,  and  there  was  the  well-executed, 


766  MEDICAL   NEWS.  [kEB. 

Strikingly-like  portrait  of  the  Professor  by  M.  Hulrcch,  under  the 
orchestra,  to  be  presented  by  him  at  the  request  of  the  Committee. 
Among  the  numerous  distinguished  persons  present  were  tlie 
Minister  of  the  Interior,  iE.  Mackay,  and  the  former  Minister, 
Heemskerk ;  from  abroad  were  Professor  Moleschott,  Rome ;  Sir 
Joseph  Lister,  London  ;  Professor  Humphrey,  Cambridge ;  Pro- 
fessor Von  Zehender,  Rostock ;  Messrs  Jonathan  Hutchison  and 
Bailey,  London ;  Hewetson,  Leeds ;  Fergus,  Glasgow ;  Berry, 
London  ;  and  Landolt,  Paris. 

On  entering  the  zaal,  among  the  hearty  cheers,  Professor  Dondeis 
was  agreeably  surprised  by  seeing  his  friend  Moleschott,  whom  he 
cordially  embraced.  In  the  name  of  the  Committee,  the  chairman, 
Jiir.  Roeil,  spoke,  saying  that  "  the  universal  accordance  of  thou- 
sands, within  and  without  this  country,  of  whom  only  a  small 
portion  could  be  present  this  day,  which  was  celebrated  as  a 
memorable  consecration,  spontaneously  and  naturally.  A  people 
that  honours  its  great  men  does  honour  to  itself  likewise.  To 
glorify  Donders  as  one  of  its  best  sons  it  magnified  its  own  renown." 
In  the  further  course  of  his  address  the  orator,  warmed  by  the 
exuberance  of  material,  directed  a  short  glance  on  the  brilliant 
career  of  our  guest,  uniting  thereby  the  entire  sentiments  of  all 
the  members  this  day  assembled.  He  mentioned  that  one  of  the 
preceptors  of  Donders's  youth,  Mgr.  Boerman,  the  present  Bishop 
of  Roesmond,  although  he  visited  numerous  educational  institutions, 
and  among  so  many  hundreds  of  students,  said  he  never  encoun- 
tered so  comprehensive  a  genius  as  Donders  already  displayed  at 
Boxmeer.  Without  previous  preparation,  he  was  called  at  24  to  the 
tuition  of  Physiology,  yet  he  nevertheless  took  at  a  stroke  a  place 
among  scientific  men.  Following  up  the  subsequent  career  of 
Donders,  tiie  speaker  brought  so  many  facts  to  recollection  that 
called  forth  the  loudest  acclamations  from  his  auditory.  But  not 
in  scientific  investigation  alone,  the  Professor's  higiiest  ambition 
was  to  benefit  humanity.  As  an  oculist,  as  originator  of  the 
Ophthalmological  School  of  Holland,  as  institutor  of  the  Hospital 
for  Eye  Diseases  at  Utrecht,  his  services  called  for  extensive  dis- 
cussion. He  then  proceeded  to  relate  how,  in  order  to  keep  the 
memory  of  his  seventieth  birthday  before  all  after-generations,  the 
Donders  Institution  was  founded,  of  which  the  Queen  was  president, 
the  Archduchess  of  Saxony  vice-president,  and  to  wiiich  donations 
flowed  in  from  all  parts  of  the  world.  Already  a  capital  of  34,000  fr. 
was  received — 21,000  fr.  from  home,  8000  foreign,  and  5000  from 
our  East  Indian  possessions.  The  contributors  were  24,000  in  all 
— 1200  internally,  500  foreign,  and  700  from  India.  The  speaker 
now  called  attention  to  tiie  Deed  of  the  Institution,  of  which  the  in- 
scription, prepared  by  Professor  Beets,  was  as  follows : — 

"  Hail,  Reader  !  On  to-day,  28th  May  1888,  being  the  seventieth 
birthday  of  Franciscus  Cornelis  Donders,  Medicine,  Honoris  Causa 
Chirargia3,  itemque  Philosophiaj  Naturalis  Doctor ;  Hon.  Doctor  of 


1889.]  MEDICAL   NEWS.  767 

Laws,  University  of  Cambridge;  Hon.  Member  of  tlie  Medical 
Faculty,  University  of  Vienna;  Commander  of  the  Order  of  tiie 
Lion,  Netherlands ;  Commander,  Officer,  Cavalier  of  undernamed 
Foreign  Orders  ;  President  of  Royal  Academy  of  Sciences ;  Mem- 
ber and  Correspondent  of  Learned  Societies,  as  well  in  Netherlands, 
India,  Belgium,  England,  France,  Italy,  Prussia,  Saxony,  Austro- 
Hungary,  Bavaria,  Russia,  Sweden,  Denmark,  North  America,  etc. 
During  a  course  of  40  years  till  to-day  Professor  of  Medicine  at  the 
College  of  Utrecht,  Founder  of  the  Ophthalmological  School  in 
Holland,  as  also  of  the  Poor's  Eye  Hospital ;  Physiologist  par 
excellence.  Desirous  to  bestow  on  this  great  and  good  man  a 
worthy  visible  testimonial  of  our  revering  gratitude  for  his  extra- 
ordinary services  to  science,  which  he,  through  his  pre-eminent  gifts 
and  indefatigable  labours,  has  powerfully  conferred  on  his  Father- 
land, whereon  he  has  renewed  and  brilliantly  advanced  the  fame 
obtained  by  Christian  Huygen,  Van  Leeuwenhoek,  and  Boeriiaave  ; 
as  also  to  suffering  humanity  for  his  support,  instruction,  loving 
healing,  and  help,  which  his  grateful  country  now  recognises. 
Now  representatives,  colleagues,  pupils,  friends,  and  admirers,  not 
only  in  Holland  and  Dutch  colonies,  but  from  all  countries  of  the 
civilized  world,  place  at  his  disposal  through  a  subscribed  fund, 
the  foundation  of  a  scientific  institution  bearing  his  honoured 
name,  with  a  special  aim  ;  the  direction  and  ordering  of  it  settled 
on  himself.  In  memory  of  our  reverence,  gratitude,  and  friendship, 
signed  by  names  of  all  present,  and  dated  Utrecht,  28th  June 
1888."  A  bronze  medal  with  the  image  of  Donders  was  presented 
with  the  book  of  inscription  to  the  Professor. 

After  the  applause  had  subsided.  Professor  Moleschott  next 
spoke.  The  previous  speaker  had  sketched  tlie  career  of  Donders, 
and  pointed  to  his  attainment  of  the  highest  pinnacle  of  science — 
equally  elevated  he  stood  in  the  friendship  that  attracted  from  the 
far  South  those  who  came  to  present  their  homage  to  him  as  a 
guide,  a  leading  ray  of  light,  in  a  moral  and  spiritual  sense.  With 
the  dignity  of  a  Roman  Senator,  might  the  speaker  greet  here  the 
jubilee;  but  he  had  also  an  official  duty  to  perform  in  the  name  of 
all  the  Italian  Universities,  but  more  expressly  that  of  Turin,  with 
which  as  Professor-Extraordinary  he  was  connected,  to  proffer  his 
congratulations.  As  Professor  Moleschott  asked  permission  from 
the  Minister  of  Education  to  go  to  Holland,  he  replied,  "  It  is  not 
a  permission  I  give  you,  but  an  instruction  I  lay  upon  you,  namely, 
to  bear  to  your  compatriot  a  letter  of  sympathy."  In  the  name  of 
Umbert  I.,  King  of  Italy,  the  speaker  was  empowered  to  present 
to  Professor  Donders  the  great  official  Cross  of  the  Order  of  the 
Crown  of  Italy. 

In  the  name  of  his  old  pupils.  Professor  Place,  of  the  University 
of  Amsterdam,  made  an  able  address,  demonstrating  the  deep 
feeling  of  gratitude  he  and  they  cherished  for  their  venerable  old 
preceptor.     Ileer  van  Roon  took  the  same  course  on  behalf  of  the 


7G8  MEDICAL  NEWS.  [fEB. 

present  pupils  at  Utreclit.  Tlie  staff  of  the  Tijdschrift  voor  Genees- 
kunde  made  special  congratulatory  felicitations ;  and  Professor 
Stokvis  displayed  his  usual  eloquence  and  brilliancy  of  diction. 
Professor  Sir  Joseph  Lister  expressed  the  congratulations  of  his 
College,  as  also  Professor  Rosenstein  those  of  the  Leidische  Academic. 
Professor  von  Zehender  represented  on  the  same  lines  the  Ophthal- 
mological  Society  of  Rostock;  and  Professor  Gunning  produced  a 
written  testimonial  from  the  Senate  of  the  University  of  Amster- 
dam, while  Professor  Nesel  represented  that  of  Luik.  The  College 
of  Groningen  sent  Professor  Iloackgeest  on  the  same  duty ;  the 
Maatschappij  tot  befordering  der  Geneeskunst  was  put  in  evidence 
by  Professor  Pekelharing  ;  and  a  great  number  of  foreign  universi- 
ties and  colleges  gave  unanimous  expression  of  the  veneration  and 
congratulation  to  the  venerable  hero  of  the  jubilee.  The  Verein 
der  Miincherer  Aerzte,  the  Academia  Reale  di  Roma,  and  the 
Imperial  Surgical  Academy  of  St  Petersburg,  all  sent  diplomas  of 
honorary  membership. 

Professor  Donders,  at  first  deeply  agitated  by  the  sight  of  the 
array  of  innumerable  faces  all  turned  towards  him  with  reverence 
and  deep  affection,  so  much,  he  said,  as  to  be  utterly  overcome, — "  I 
cannot  reply  to  you  all ;  I  am  unfit  for  it.  At  the  same  time,  I 
have  often  during  these  last  days  asked  myself,  How  have  I  merited 
this?  I  have  often  thought  over  my  past  life,  and  am  deeply  con- 
scious that  these  homages  are  undeserved,  and  that  you  all  over- 
estimate my  claims.  The  circumstances  surrounding  me  have  had 
much  to  do  with  my  career,  more  than  my  talents.  I  have  to 
thank  being  born  under  a  lucky  star."  Following  on  the  lines  of 
Heer  Roell,  the  speaker  went  on  to  mention  the  delight  he  took  in 
tuition  when  at  24  years  he  was  appointed  teacher,  at  the  School  of 
Military  at  Utrecht,  of  Physiology  and  Tissue  Investigation.  Mulder 
was  the  first  examiner,  showing  that  chemistry  began  where  mor- 
phology ended.  Chemistry  could  be  studied  under  the  microscope. 
Mulder  honoured  him  by  joining  with  him  in  these  examinations. 
Van  Deen  instructed  him  in  the  experiments  on  the  nervous  system 
of  frogs,  which  Johan  Miiller  first  instituted.  His  intercourse  with 
the  pupils  of  Miiller's  school,  Helmholtz  and  Carl  Ludwig, 
was  one  of  the  auspicious  circumstances  to  which  he  referred.  In 
1851  a  journey  to  London  connected  with  the  University  of  Utrecht 
brought  him  into  contact  with  Von  Grafe,  from  whom,  after  three 
weeks'  acquaintance,  he  parted  as  from  a  brother ;  and  then,  as  he 
thereupon  resolved  to  devote  himself  to  the  practice  of  ophthalmology, 
was  the  ophthalmoscope  discovered.  A  call  came  to  him  from 
Bonn  to  replace  Helmholtz  in  physiology.  This  led  him  to  speak 
of  his  former  pupil  and  assistant  Snellen,  afterwards  his  successor, 
as  also  his  amanuensis  for  near  thirty  years,  Kugenaar,  a  man 
who  received  and  deserved  his  warm  friendship — one  who,  without 
knowing  or  caring  for  it,  was  a  mechanician  whose  instruments 
were  sent  all  the  world  over.     With  the  function  of  tuition,  ever 


188!).]  MEDICAL   NEWS.  760 

an  enjoyment  to  him,  he  had  the  privilege  to  do  something  in 
favour  of  science  and  instruction,  now  that  the  law  enjoining  him 
to  resign  his  charge  came  into  force.  He  now  referred  to  the  funds 
placed  at  his  disposal  for  the  institution  of  the  Hospital  for  Eye 
Diseases.  But,  to  enable  this  Institution  to  attain  to  the  highest 
point  of  efficiency,  a  greater  sum,  one  or  two  tons  additional 
(100,000  or  200,000  guelden),  were  requisite.  He  advised  the 
interest  so  to  be  applied  that,  on  the  accumulation  of  1000  fr.  for 
eight  years,  two  meritorious  students  might  have  the  opportunity 
of  advancing  their  studies  in  foreign  countries.  He  trusted  the 
first  assistant  in  the  Pliysiological  Laboratory  and  the  one  at  the 
Eye  Infirmary  might  have  the  preference.  He  concluded  by  re- 
turning thanks  to  all  present  who  had  come  to  do  him  honour, 
more  especially  to  the  above-named  speakers.  He  had  to  state 
also  that  H.M.  the  King  had  resolved  to  bestow  on  him  the 
Cross  of  2nd  Class  of  the  Golden  Lion  of  Nassau. 

At  the  dinner  which  followed  200  gentlemen  were  present — Heer 
Roell  in  the  chair.  After  the  loyal  toast  to  the  King,  I)r  Blora 
Coster  proposed  that  of  the  guest  of  the  evening.  Professor  Donders, 
as  a  man  born  in  these  lowlands  to  raise  them  to  the  highest  point 
of  elevation  of  mind.  Many  speeches  of  praise  and  congratulation 
were  delivered,  and  all  who  had  contributed  to  the  success  and 
enjoyment  of  the  celebration  were  duly  acknowledged. 

Royal  College  of  Physicians,  Edinbokgh. — The  following  gentleman  passed  his 
final  examination  for  the  degree  in  Medicine  at  the  sittings  held  on  4th  January 
1889,  and  was  admitted  L.R.C.P.  Ed.: — Milne  Brownlee,  Crosshill,  Canada. 

Royal  Colleges  of  Physicians  and  Surgeons,  Edinbdrgh,  and  Faculty  of 
Physicians  and  Surgeons,  Glasgow. — The  following  candidates  passed  their  final 
examination  for  the  triple  qualification  in  Medicine  and  Surgery  at  the  sittings  held 
in  January  1889,  and  were  admitted  L.R.C.P.  &  S.  Ed.,  and  L.F.P.  &  S.  Glasg.  :— 
Walter  MacDonnell  Kelly,  Crook,  Durham;  Arthur  Henry  Poole,  Brightmet,  near 
Bolton;  Thomas  Frank  Southam,  Cheshire;  James  Arthur  Thomas  Hall,  Burton-on- 
Trent;  Agnes  Douglass  Craine,  Ontario,  Canada;  James  England  Brogden,  Hants; 
Francis  Seymour,  Fairbridge,  South  Africa ;  John  Thomson  Biernackid,  Allahabad ; 
John  Morgan  Whiteford,  Co.  Antrim;  Alfred  James  M'Farlane  Stenhouse,  Dun- 
fermline ;  William  Sinclair  Cameron,  Liverpool ;  George  Elliott,  Derry ;  Henry  M'Neal 
Smith,  Canada ;  Percy  William  Menzies,  Maidstone ;  Charles  Augustus  Bynoe, 
Barbadoes ;  Walter  Smithies,  Lancashire ;  Robert  George  Spiller,  Cork ;  John 
Joseph  Ashley  Keane,  County  Kerry;  Clarence  Alfred  Joseph  Wright,  Madras; 
Clifton  Sturt,  London ;  Andrew  Wilson,  Co.  Antrim ;  William  Smith,  Jamaica ;  David 
Montgomerie  Paton,  Hurlford,  Ayrshire;  Antonio  Caesar  Rodrigues,  Demerara; 
James  Harvey  Martin,  Ballynahinch ;  William  Patrick  O'Meara,  Co.  Limerick  ; 
Edmund  George  Howard,  Clitheroe;  Linford  Elfe  Row,  Sydney;  George  Herbert 
Rutter,  London ;  James  Menzies,  Kenmore,  Perthshire  ;  William  Henry  Frederic 
Fenn  Godwin,  London;  William  Shortt,  King's  County;  William  Power  Everard, 
Athlone;  David  Kinnear  Draffin,  Ballybay,  County  Monaghan;  William  Smyth 
Crawford,  County  Down  ;  Alexander  John  Keiller,  Edinburgh  ;  Edward  Blackwell 
Roberts,  Mold ;  Ernest  James  Cheetham,  Rochdale  ;  James  Aloysius  O'Sullivan, 
Kingstown  ;  Adam  Ramage,  Kilmarnock ;  Herbert  Heyworth,  Nelson,  Lancashire ; 
and  Bangard  Annassamy  Sinnatambou,  Port  Louis,  Mauritius. 

Royal  College  of  Surgeons,  Edinburgh. — The  following  gentlemen  passed 
their  final  examination  for  the  degree  in  Surgery  at  the  sittings  held  in  January 
1889,  and  were  admitted  L.R.C.S.  Ed.: — Henry  Knowles,  Yeadon,  Leeds;  Kenneth 
M'Kinnon  Douglas,  Edinburgh  ;  Sydney  Harry  Applebj'  Stephenson,  Nottingham  ; 
and  Theophilus  Bulkeley  Hyslop,  Inverness. 

EDINBURGH    MED.    JOURN.,   VOL.    XXXIV. — NO.    VIII.  6  K 


770  MKDICAL   NEWS.  [FEB. 

A  VERY  Valuable  Lesson  for  those  who  use  Anaesthetics. 
— Dr  Julian  J.  Chisliolm,  of  Baltimore,  Md.  (Medical  Record^  Jan. 
21st,  1888),  relates  the  case  of  a  healthy  and  robust  child  of  three, 
in  whom,  while  attempting  to  extirpate  a  gliomatous  mass  from  the 
eye,  symptoms  of  dangerous  chloroform  narcosis  occurred.  These 
were  relieved  by  suspension  of  the  patient,  head  downwards,  until 
respiration  and  pulse  were  re-established.  This  occurred  three 
times  during  the  operation,  and  the  operator  was  finally  compelled 
to  finish  the  operation  with  the  patient  in  this  position.  No  other 
measures  for  the  restoration  of  the  patient  were  resorted  to. 

In  spite  of  the  anxieties  incident  to  such  an  occurrence,  and  the 
fact  that  it  is  one  occurring  to  him  "  now  and  then,"  the  author 
still  asserts  his  preference  for  chloroform  as  an  anaesthetic.  His 
advocacy  of  it  is  based  upon  an  experience  of  at  least  ten  thousand 
administrations  without  a  single  death.  He  uses  an  inhaler  or 
towel  folded  in  a  cone  form,  with  the  apex  of  the  cone  open  for  the 
free  entrance  of  air.  If  the  ears  remain  pink,  he  does  not  trouble 
himself  about  the  pulse.  The  usual  precautions  of  drawing  the  chin 
forcibly  upwards,  thus  pulling  the  anterior  wall  of  the  pharynx  and 
the  hyoid  bone  and  root  of  the  tongue  forward,  making  for  the  air 
a  clear  and  straight  passage  into  the  lungs,  are  practised  when 
snoring  or  other  evidences  of  obstructed  breathing  occur. — Brooklyn 
Medical  Journal,  April  1888. 

Strange  Cures. — For  hydrophobia,  the  most  deadly  and  most 
feared  of  all  the  accidents  and  ills  to  which  man  may  be  liable, 
there  is  a  locality  in  England  where  the  following  treatment  is 
believed  in: — The  afflicted  person  must  be  laid  on  his  back;  then 
his  nose  must  be  pricked  three  times  and  three  passes  of  tiie  hand 
made  over  him,  whilst  these  words  are  recited  with  solemnity  and  due 
emphasis,  "I  am  thy  Saviour,  lose  not  thy  life!"  After  that  he 
must  be  enveloped  in  blankets  to  "  sweat  him,"  and  pills  must  also 
be  administered  to  him  made  of  the  skull-bone  of  a  man  who  has 
been  murdered  or  who  has  met  with  a  violent  death  ;  the  result  being 
that  the  sufferer  unfailingly  recovers ! 

In  some  of  the  southern  shires  it  is  considered  that  three  sips  of 
sacramental  wine  are  an  unfailing  cure  for  attacks  of  intermittent 
hiccough. 

Should  smallpox  make  its  appearance  in  a  house,  a  frog  must  be 
dried  alive  in  an  oven,  and  then  stitched  up  in  a  bag  and  hung 
round  the  neck  of  the  person  attacked  by  the  fell  disease,  where- 
upon this  also  will  disappear  with  magical  rapidity. — Florence 
Layard  in  the  Chemist  and  Druggist. 

Vaporoles. — Messrs  Burroughs,  "Wellcome,  &  Co.  have  sent  us 
a  sample  box  of  the  new  preparations  to  which  they  have  given  the 
name  of  "  Vaporoles."  Tiiese  are  small  glass  capsules  containing 
the  necessary  quantity  of  a  medicament  to  be  used  either  for 
inhalation  or  fumigation.  The  capsule  is  surrounded  by  a  layer  of 
absorbent  cotton,  which  is  enclosed  in  a  silk  cover.     When  required 


1889.]  MEDICAL   NEWS. — OBITUARY.  771 

for  use  the  capsule  is  broken,  tlie  cotton  absorbs  the  fluid,  and  if  an 
inlialation  be  wanted,  it  is  dropped  into  the  inhaler  and  used  in  the 
ordinary  way.  If  a  fumigation  has  been  ordered,  it  is  placed  on  a 
dry  hot  plate.  Carbolic  acid,  ether,  amyl  nitrite,  compound  tincture 
of  benzoin,  chloroform,  creasote,  cubebs  and  lemon,  iodine  tincture, 
juniper  terebene,  pinol,  and  eucalyptus  are  the  drugs  which  have 
been  put  up  in  this  way.  We  have  had  an  opportunity  of  trying 
several  of  these,  and  have  found  tliem  very  efficacious,  and  think 
them  an  improvement  on  the  old  style  of  dispensing  drugs  for 
inhalation. 

Birmingham  Medical  Eeview. — For  sixteen  years  the  Birming- 
ham Ifedical  Review  has  efficiently  represented  the  current  state 
of  medical  science  and  practice  in  the  Midland  District  of  England. 
Circumstances  have,  however,  brought  about  a  change  in  the 
management  of  the  Review,  and  Eobert  Saundby,  M.D.  Ed., 
F.K.C.P.  Lond.,  Lawson  Tait,  F.R.C.S.  Eng.,  M.D.,  LL.D.,  and 
Gilbert  Barling,  M.B.,  B.S.  Lond.,  F.R.C.S.  Eng.,  have  undertaken 
its  responsibility  for  the  future.  The  size  of  each  number  is  to  be 
increased  from  48  to  64  pages,  and  at  the  same  time  the  price  is 
to  be  reduced.  We  trust  the  enterprise  of  our  contemporary 
will  be  well  rewarded  by  an  increased  circulation. 


OBITUARY. 


ARCHIBALD  INGLIS,  M.D.,  F.R.C.S.  Ed. 

In  1717  Alexander  Inglis  was  admitted  a  member  of  the 
Incorporation  of  Surgeons  of  Edinburgh ;  his  son  William  Inglis 
was  admitted  a  member  of  the  Incorporation  in  1743,  and  in 
1782-3  and  1790-1  was  President  of  the  Royal  College  of 
Surgeons,  The  Incorporation  had-  been  made  a  Royal  College  by 
Royal  Charter  in  March  1778.  William  Inglis  had  three  sons ; 
the  third  was  Andrew  Inglis  who,  born  in  1767,  became  a  Fellow 
of  the  College  in  1789,  and  its  President  in  1808-9  j  he  died  in 
1834.  By  his  wife  Janet,  a  daughter  of  Thomas  Spens  of  Lathallan, 
he  had  three  sons,  all  of  whom  entered  the  medical  profession, 
Archibald  Inglis,  the  second  of  these,  was  born  on  4th  December 
1801.  He  became  a  Fellow  of  the  Royal  College  of  Surgeons  in 
1825,  and  filled  the  office  of  President  in  1853-4.  He  was 
connected  with  the  College  in  many  official  capacities — Librarian, 
Examiner,  and  Assessor — till  he  died  after  a  brief  illness  on 
Thursday,  3rd  January  1889.  For  172  years  four  successive 
generations  of  Inglises  have  been  connected  with  the  Royal  College 
of  Surgeons  without  a  break.  By  the  death  of  the  good  old  man 
this  long  continuity  of  service  is  finished  ;  but  in  the  memory  of  all 
those  who  knew  him  Archibald  Inglis  will  always  be  tenderly 
cherished.  He  was  a  man  emphatically  without  guile ;  modest  and 
retiring  almost  to  a  fault,  he  never  asserted  himself  or  his  opinions. 
With  all  his  hereditary  and  personal  knowledge  of  the  College  and 


772  OBITUARY.  [FEB. 

its  affairs,  he  often  kept  quiet  when  younger  and  less  informed  men 
were  laying  down  the  law  with  fluency  and  assurance  ;  yet  if  the 
occasion  required  him  to  speak,  he  would  do  it  with  calmness  and 
dignity.  Pie  was  a  man  of  high  culture  ;  in  these  unlettered  days  he 
kept  up  his  classical  knowledge  and  reading.  He  was  one  of  the  old 
school  of  Examiners  who  could  give  a  sensible  practical  examina- 
tion well  suited  to  test  a  candidate's  knowledge  in  many  subjects. 
Chemistry  and  Anatomy  he  knew  well.  As  a  family  practitioner 
he  was  able,  conscientious,  and,  above  all,  gentle  and  considerate. 
As  good  to  the  poor  as  to  the  rich,  he  worked  in  Greenside 
parish  as  long  as  he  was  able.  To  an  advanced  age  he  did  not 
spare  himself;  as  Registrar  of  Examinations  he  had  many  a  hard 
day's  work  amid  schedules  and  certificates  at  an  age  when  most 
men  would  have  been  fit  for  little  but  repose. 

Above  all  he  was  a  Christian  gentleman.  In  these  days  of  push 
and  self-assertion,  no  one  can  say  that  Archibald  Inglis  ever  did 
an  action  or  said  a  word  which  could  in  any  way  hurt  or  even 
disparage  a  brother  practitioner.  As  advancing  years  caused  him  to 
be  gradually  less  employed  in  practice,  he  took  his  enforced  leisure 
gracefully,  recognising  the  inevitable. 

Predeceased  by  his  wife,  a  family  of  sons  and  daughters  still 
survives.  His  eldest  son  Andrew,  Professor  of  Midwifery  in 
Aberdeen,  died  some  thirteen  years  ago  at  a  comparatively  early  age. 


DR  GEORGE  WILLIAM  BELL. 

To  most  of  the  present  generation  of  medical  men  in  Edinburgh, 
the  notice  in  the  daily  newspaper  that  Dr  George  William  Bell,  late 
of  Edinburgh,  died  at  Leamington  on  the  6th  of  January  1889,  will 
convey  little  information  ;  for  Dr  Bell,  though  not  a  very  aged  man, 
has  for  so  many  years  been  laid  aside  from  active  work,  and  for  so 
many  more  years  had  given  up  strictly  professional  labours,  that  he 
had  almost  dropped  from  the  recollection  of  most  of  his  professional 
brethren.  He  came  of  a  good  old  Edinburgh  stock.  His  grand- 
father, Benjamin  Bell,  was  a  well-known  surgeon  and  voluminous 
author,  in  whose  six  volumes  much  will  yet  be  found  to  repay  reading, 
and  stimulate  the  reflection  that  our  ancestors  had  in  their  thoughts 
the  germs  of  many  later  discoveries.  He  had  four  sons,  the  eldest 
of  whom,  George,  was  a  well-known  surgeon,  a  brilliant  operator,  and, 
above  all,  a  most  rapid  and  successful  lithotomist.  George  William, 
of  whom  we  now  are  writing,  was  one  of  two  sons  of  George,  who 
followed  their  father's  profession.  The  eldest,  Benjamin,  author 
of  a  well-known  book  on  diseases  of  the  bones,  died  at  a  com- 
paratively early  age.  George  William  studied  in  Edinburgh, 
London,  and  Paris,  enjoyed  a  very  full  curriculum,  much  hospital 
opportunity,  and  was  zealous  and  interested  in  his  work,  taking 
the  L.R.C.S.  Ed.  and  M.D.  Edin.  in  1835.  Though  well  equipped 
for  work,  and  with  a  manner  and  appearance  likely  to  help  him, 
with  his  good  opening  and  opportunity,  he  never  settled  down  to 


1889.]  DR   GEOIIGE   WILLIAM   BELL.  773 

the  drudgery  of  practice,  and  on  being  appointed  a  District  Inspector 
of"  Registers,  practically  gave  up  the  profession.  He  was  a  man, 
however,  of  great  industry  in  his  own  way,  and  full  of  zeal  for 
humanity.  He  devoted  himself  to  ragged  school  work  under  his 
friend  Dr  Guthrie,  whom  he  both  admired  and  loved,  and  did 
much  good  work  in  the  closes  of  Edinburgh  long  before  '*  slum- 
ming "  was  a  fashion.  His  pamphlet  on  Blackfriars  Wynd  involved 
immense  personal  labour,  and  opened  the  eyes  of  the  public  to  the 
overcrowding  and  indecency  of  the  Edinburgh  closes  in  a  very 
remarkable  way.  His  work  as  Inspector  of  Registers  gave  him,  in 
the  many  journeys  he  had  to  take  to  outlying  and  out  of  the  way 
parishes,  much  opportunity  of  pleasant  intercourse  and  antiquarian 
research.  He  was  also  able  to  delight  his  friends  with  many  quaint 
anecdotes,  which  he  told  admirably.  His  Gaelic  sermon  (none  the 
worse,  possibly,  from  the  fact  that  he  did  not  know  a  word  of  the 
language)  was  often  asked  for.  He  very  nearly  changed  his  work 
when  in  1862  he  was  appointed  Deputy  Commissioner  in  Lunacy, 
but  as  he  found  it  would  involve  long  and  frequent  absences  from  his 
aged  mother,  he  declined  the  appointment.  His  health  began  to  fail. 
A  rapidly  matured  cataract  was  successfully  operated  on,  but  repeated 
attacks  of  a  paralytic  affection  gradually  made  him  more  and  more 
of  an  invalid,  till  at  last  for  many  years  he  was  practically 
confined  to  his  chair.  However,  he  was  a  most  cheerful  and 
contented  invalid — always  glad  to  see  old  friends  and  relatives. 
Attended  by  a  most  devoted  wife,  he  spent  most  of  his  time  at 
English  watering  places,  where  he  could  get  more  sun  and  a  more 
genial  climate  than  that  of  Edinburgh. 

To  the  last  he  maintained  his  interest  in  politics  of  Church  and 
State,  in  the  advances  of  surgery  and  medicine,  and  specially  in  the 
careers  and  progress  in  life  of  all  his  countless  nephews,  nieces,  and 
cousins  of  every  degree.  One  by  one  his  old  friends  died — Drs 
Guthrie,Bruce,and  Hanna,Mr  Benjamin  Bell, Mr  Gibson  Thomson — 
till  at  length  in  his  visits  to  Edinburgh  sadly  few  of  his  own  compeers 
remained.  Lord  Moncreiff,  Sir  Douglas  Maclagan,  and  Mr  Wm. 
Mackellar,  could  still  talk  to  him  of  old  times,  and  their  visits  used 
to  cheer  him;  he  seemed  young  again,  and  he  could  hold  his  own  in 
jest  and  story.  An  estimable,  upright,  and  loving  man,  he  served 
his  generation  while  he  could  work,  and  possessed  himself  in  patience 
when  he  had  to  rest. 


GEORGE  DUFF,  M.A.,  M.D.,  ELGIN. 

Within  the  past  few  years  several  prominent  members  of  the 
profession  in  the  North  of  Scotland  have  been  removed  by  death. 

Little  more  than  two  years  ago  Dr  Grigor  of  Nairn  and  Rome, 
and  in  May  last  year  Dr  Ross  of  Elgin,  contemporary  students  and 
life-long  friends,  were  taken  from  us.  And  now,  again,  since  the 
opening  of  this  year,  another,  only  a  few  years  their  junior,  Dr 
George  Duff  of   Elgin,  in   the  midst  of  much  active  usefulness, 


774  OBITUARY. — CORRESPONDENCE.  [FEB. 

has  suddenly  passed  away.  On  1st  January  he  did  his  usual 
round  of  work  after  attending  the  New  Year's  service  in  the 
Established  Church,  and  that  evening  was  seized  with  erysipelas 
of  the  head  and  face,  from  which,  congestion  of  tlie  lungs  having 
supervened,  he  died  on  11th  January  in  his  69th  year. 

Born  in  Elgin  in  1819,  Dr  DufF  was  descended  from  an  old 
family,  many  members  of  which  occupied  positions  of  great  influ- 
ence and  responsibility  in  the  county  of  Moray  during  tlie  past 
century.  He  was  educated  at  Elgin  Academy  and  King's  College, 
Aberdeen,  where  he  graduated  Master  of  Arts  in  1838.  He 
studied  medicine  in  Edinburgh,  and  took  his  M.D.  degree  in  1841. 
He  practised  for  some  time  in  Genoa,  then  in  London,  and  re- 
turned to  Elgin  in  1856,  where  he  spent  the  rest  of  his  life. 
Among  the  appointments  which  he  held  at  his  death  were  the 
physicianships  of  Gray's  Hospital  and  Anderson's  Institution.  In 
the  discharge  of  his  duties  in  connexion  with  these  he  was  most 
assiduous  and  methodical,  and  in  fulfilling  all  his  engagements  he 
was  most  punctual  and  exact.  Unostentatious,  retiring,  and  modest, 
he  always  bore  himself  as  a  true  gentleman,  and  held  a  high  place 
in  the  esteem  and  respect  of  all  his  professional  brethren.  He  did 
not  contribute  much  to  the  journals,  but  he  wrote  with  purity  and 
grace,  and  often  read  papers  of  interest  at  the  meetings  of  the 
Northern  Counties  Branch  of  the  British  Medical  Association,  of 
which  he  was  one  of  the  founders,  and  some  years  ago  its  President. 

He  was  a  Justice  of  Peace  of  the  county,  and  often  took  his 
part  in  administering  justice.  For  several  years  he  was  a  member 
of  the  Burgh  School  Board,  and  at  the  time  of  his  death  president 
of  several  local  societies.  No  later  than  October  last  a  new  street, 
now  being  formed,  was  named  in  his  honour  "  DufF  Avenue." 

He  was  also  an  elder  of  the  Established  Church  of  Scotland,  and 
frequently  sat  in  the  General  Assembly  as  representative  of  the 
Presbytery  of  Elgin. 

In  private  life  Dr  DufF  was  much  beloved,  and  much  sympathy 
is  felt  in  the  community  with  his  family  in  their  bereavement. 
On  15th  January  his  remains  were  followed  to  the  family  tomb 
within  the  grounds  of  the  Elgin  Cathedral  by  a  large  concourse  of 
mourning  friends ;  and  there  till  the  resurrection  morn  they  rest 
beside  that  hoary  noble  pile,  which  he  was  wont  to  consider  the 
finest  architectural  ruin  in  his  native  land. 


COERESPONDENCE. 


To  the  Editor  of  the  Edinburgh  Medical  Journal. 
DURATION  OF  INCUBATION  AND  CONTAGIOUSNESS. 

Sir, — Ten  years  ago  the  Clinical  Society  of  London  appointed  a 
Committee  to  investigate  the  periods  of  incubation  and  of  con- 
tagiousness of  the  commoner  communicable  diseases. 


1889.]  CORRESPONDENCE,   ETC.  775 

A  certain  amount  of  valuable  material  was  received,  but  it  was 
thought  desirable  to  defer  the  presentation  of  a  report  until  further 
experience  was  available.  The  Society  has  now  determined  to 
gather  additional  information  with  a  view  to  the  preparation  of  an 
early  report  on  the  subject,  and  for  this  purpose  has  reconstituted 
the  Committee. 

The  Committee  is  desirous  of  obtaining  particulars  of  cases  which 
throw  light  upon  the  periods  of  incubation  and  contagiousness  of 
the  below-mentioned  diseases,  and  will  be  grateful  for  notes  of  any 
cases  where  the  facts  can  be  ascertained  with  sufficient  precision  to 
afford  grounds  for  conclusions. 

It  is  thought  that  gentlemen  practising  at  a  distance  from  large 
centres  of  population,  and  especially  those  engaged  in  the  Public 
Health  Service,  or  associated  with  schools,  would  be  able  to  supply 
information  of  tlie  kind  required.  A  single  case  in  which  the 
dates  of  exposure  to  infection  and  the  appearance  of  the  first 
symptom  can  be  accurately  fixed,  especially  where  the  exposure 
has  been  limited  in  duration,  would  be  highly  valued. 

The  following  diseases  are  included  within  the  scope  of  the 
inquiry : — 


Variola. 

Typhus. 

Cholera. 

Varicella. 

Relapsing  Fever. 

Erysipelas. 

Measles. 

Whooping-cough. 

Mumps. 

German  Measles. 

Diphtheria. 

Infectious  Sore 

Scarlet  Fever, 

Enteric  Fever. 

Throat. 

The  Committee  consists  of  Dr  W.  H.  Broadbent,  Dr  George 
Buchanan,  Dr  Cayley,  Dr  Thomas  Barlow,  Dr  Alfred  Hill,  Dr 
Isambard  Owen,  Dr  Thome  Thorne,  Dr  Alder  Smith,  and  Mr  R. 
W.  Parker,  with  Mr  Shirley  Murphy,  41  Queen  Anne  Street,  and 
Dr  Dawson  Williams,  25  Old  Burlington  Street,  W.,  as  Honorary 
Secretaries,  to  one  of  whom  communications  should  be  addressed. 
— I  am,  etc.,  W.  H.  Broadbent, 

Chairman  of  Committee. 

Clinical  Society  of  London, 
January  1889. 

P.S. — An  early  answer  would  facilitate  the  work  of  the  Committee 


PUBLICATIONS  RECEIVED. 


James  Braithwaite,  M.D., — Retrospect  of  MemoirsandMemorandaof  Anatomy.   Vol.1. 

Medicine.     Vol.98.     Sirapkin,  Marshall,  Williams&Norgate,  F-iond.andEdin.,1889. 

&  Co.,  Lond.,  1889.  Report  by  the  Clinical  Society  of  London 

C.  M.  Campbell,  M.D., — The  Skin  Diseases  on   Myxoedema.      Longmans,    Green,   & 

of  Infancy  and  Early  Life.    Ballifere,  Tin-  Co.,  Lond.,  1888. 

dall,  &  Cox,  Lond.,  1889.  A.    Humboldt    Sexton,     F.R.S.E.,    etc., 

Guy's  Hospital  Reports.     Vol.  45.     J.  &  A.  —  Elementary      Inorganic       Chemistry. 

Churchill,  Lond.,  1889.  Blackie  &  Son,  Lond.,  1889. 

W.  H.  A.  Jacobson,  M.  a.,  M.B.,  etc., — The  Statistical  Report  of  the  Health  of  the  Navy, 

Operations  of  Surgery.   J.  &  A.  Churchill,  1887. 

Lond.,  1889.  Thirty-second   Detailed   Annual   Report  of 


776 


PUBLICATIONS   AND   rEHIODICALS   RECEIVED.       [fKI;.  1-80- 


the  Registrar-General  of  Births,  Deaths, 

and  Marriages  in  Scotland. 
Transactions    of    the    American    Otological 

Society.     Vol.  4,  Part  2.     New  Bedford, 

Mass.,  1888, 
Transactions  of  the  Association  of  American 

Physicians.     Vol.  3.     Philadelphia,  1888. 


Transactions  of  the  Pathological  Society  of 

London.     Vol.  39.     Smith,  Elder,  &  Co., 

Lond.,  1888. 
The  Life  Register.    West,  Newman,  &  Co., 

Lond.,  1888. 
Year-Book  of  Treatment  for  1889.     Cassell 

&  Co.,  Lond. 


PERIODICALS  RECEIVED. 


Abstract  and  Index, — July-Oct. 
Albany  Medical  Annals, — Nov. .  Dec. 
American  Journal  of  Obstetrics, — Dec,  Jan. 
American  Journal  of  the  Medical  Sciences, 

—  Dec,  Jan. 
American  Lancet, — Dec,  Jan. 
American  Practitioner  and  News, — Nov.  24- 

Jan.  5. 
Annales  d'Oculistique, — Nov. 
Annales  de  Dermatologie,  etc., — Nov.,  Dec. 
Annales  des  Maladies  des  Organes  G^nito- 

urinaires. — Jan. 
Annales  des  Maladies  de  I'Oreille,  etc., — 

Dec,  Jan. 
Annales  Medico-Chirurgicales, — Oct. 
Archives  de  Tocologie, — Nov.-Jan. 
Archives   G^ne'rales   de  M^decine, —  Dec, 

Jan. 
Archives  of  Gynaecology, — Dec. 
Archives  de  Physiologic  normale  et  patho- 

logique. —  Nos.  1,2. 
Archives  of  Pediatrics, — Dec,  Jan. 
A  sclepiad, — Nov. 

Australasian  Medical  Gaiette, — Nov.,  Dec 
Berliner    Klin.    Wochenschrift,  —  Dec.    3- 

Jan.-21. 
Birmingham  Medical  Review, — Dec,  Jan. 
Births,    Deaths,    and    Marriages,    Monthly 

Return  of, — Nov.,  Dec. 
Boston   Medical    and    Surgical    Journal, — 

Nov.  15-Jan.  10. 
British  Journal  of  Dermatology, — Jan. 
British  Medical  Journal, — Dec.  1-Jan.  26. 
Bristol  Medico-Chirurgical  Journal,— Dec. 
British  Gynaecological  Journal, — Nov. 
Brooklyn  Medical  Journal, — Nov.,  Dec. 
Bulletins  et  M^moires  de  la  Soci^te  Obst^t- 

ricale  et  Gyndcologique  de  Paris, — Nov., 

Dec 
Bulletin  G^n^ral  de  Th^rapeutique, — Nov. 

30-Jan.  15, 
Centralblatt  fiir  Gynakologie,— Dec.  1-Jan. 

19. 
Centralblatt  fiir  Chirurgie,— Dec.  1-Jan.  19. 
Centralblatt   fiir    Bacteriologie    und    Para- 

sitenkunde,— Bd.  4,   Nos.  22-26,  Bd,  5, 

Nos.  1-4. 
Chemist  and  Druggist, — Dec.  1-Jan.  19. 
Chicago  Medical  Journal  and  Examiner, — 

Dec. 
Dublin  Journal  of  Medical  Science,— Dec, 

Jan. 
France  M^dicale,—  Nov.  27- Jan.  24. 
Gazette  des  Hopitaux, — Nov.  27-Jan.  26. 
Gazette  M^dicale  de  Paris, — Dec.  1-Jan.  26. 
Gazzetta  Medica  di  Torino,— Oct.  25-Dec.  25. 
Gazette  Hebdomadaire  des  Sciences  MMi- 

cales  de  Bordeaux,— Dec.  2-Jan.  20. 
Glasgow  Medical  Journal, — Dec,  Jan. 


Index  Medicus, — Nov.,  Dec. 
Indian  Medical  Gazette, — Nov. 
International  Journal  of  Surgery  and  Anti- 
septics.—Oct. 
Jahrbuch  fiir  Kinderheilkunde,— Band  29, 

Heft  1. 
Journal  de  Medecine  de  Bordeaux, — Dec, 

2-Jan.  20. 
Journal   de  Medecine  de   Paris, — Dec.   2- 

Jan.  27. 
Journal  of  Anatomy  and  Physiology,— Jan. 
Journal    of    Comparative    Pathology    and 

Therapeutics, — Dec. 
Journal  of  Cutaneous  and   Genito- Urinary 

Diseases, —  Dec,  Jan. 
Journal  of  Laryngology  and  Rhinology, — 

Dec,  Jan. 
Journal  of  Mental  Science,— Jan, 
Journal  of  Nervous  and  Mental  Disease, — 

Oct.,  Nov. 
Journal  of  the  American  Medical  Associa- 
tion,— Nov.  17-Jan.  5. 
Journal  of  the  British  Dental  Association, — 

Dec,  Jan. 
Klinische  Monatsblater  fiir  Augenheilkunde, 

— Dec,  Jan. 
L'Anomalo  Gazzettino  Antropologico,  etc., 

— Jan. 
London  Medical  Record,— Dec,  Jan, 
Maryland  Medical  Journal. —  Dec. 
Medical  Chronicle, — Dec,  Jan. 
Medical  Press  and  Circular, —  Nov,  28-Jan. 

23. 
Montreal  Medical  Journal, — Jan. 
New  York  Medical  Journal, — Nov.  24-Jan, 

12. 
Nouveaux  Remfedes. — Dec.  8. 
Nouvelles    Archives    d'Obst^trique    et    de 

Gynecologic, — Nov.,  Dec 
Occidental  Medical  Times, — Jan. 
Philadelphia  Medical  and  Surgical  Reporter, 

Nov.  10-Jan.  12 
Philadelphia  Medical  News, — Nov.  24-Jan. 

5. 
Philadelphia  Medical  Times, — Dec,  Jan. 
Polyclinic, —  Nov.,  Dec. 
Practitioner, — Dec,  Jan. 
Progrfes  Medical, — Dec.  15-Jan.  14. 
Progresso  Medico, — Jan. 
Revue  de  Chirurgie,  — Dec,  Jan. 
Revue  G^n^rale  de  Clinique  et  de  Th€ra- 

peutique,  —  Nov.  29- Jan.  24. 
Sacramento  Medical  Times, — Dec. 
St  Louis  Courier  of  Medicine,— Nov.,  Dec. 
Therapeutic  Gazette, — Dec. 
Transactions  of  the  Sei  i  Kwai, — Nov.,  Dec, 
Virchow's  Archiv, — Dec.,  Jan. 
Weekblad  van  bet  Nederlandsch  Tijdschrift 

Geneeskunde, — Dec,  Jan. 


OEIGINAL    COMMUNICATIONS. 

L— CASE  OF  ACUTE  INTUSSUSCEPTION  IN  A  CHILD 
THREE  YEARS  OF  AGE  SUCCESSFULLY  RELIEVED  BY 
ABDOMINAL  SECTION. 

By  Thomas  Annandale,  F.R.C.S.,  Regius  Professor  of  Clinical   Sitrgery, 
University  of  Edinburgh. 

(Bead  before  the  Medico-Chirurgical  Society  of  Edinburgh,  Qth  Febniary  1889.) 

I  RECORD  a  note  of  the  following  case  in  order  to  emphasize  the 
importance — an  importance  which  is  now  very  generally  acknow- 
ledged by  surgeons — of  early  operation  in  cases  of  acute  intus- 
susception, or  other  forms  of  acute  intestinal  obstruction,  when 
other  means  have  failed  to  relieve  the  condition  after  a  careful 
trial  of  them. 

It  is  true  that  in  a  small  number  of  cases  of  intussusception 
(about  6  per  cent,  in  patients  between  the  ages  of  2  and  5  years, 
according  to  Leichtensterns^),  spontaneous  elimination  by  gangrene 
of  the  gut  takes  place,  but  a  certain  proportion  of  such  cases  do 
not  ultimately  recover,  but  die  from  causes  in  connexion  with  the 
intestinal  condition  ;  and  therefore  it  must  be  considered  that, 
unless  an  acute  intussusception  is  relieved  in  the  early  stages  of 
the  case,  it  is,  especially  in  young  children,  a  very  fatal  disease. 

The  treatment  of  this  affection  by  enemata  or  insufflation  can 
only  be  successful  in  its  early  stages,  although  a  few  exceptional 
cases  have  been  recorded ;  and  it  should  always  be  remembered 
that  in  the  later  stages  this  treatment  is  attended  with  consider- 
able risks. 

An  interesting  point  in  my  case  is  the  failure  of  the  enemata, 
and  the  introduction  of  a  bougie  to  relieve,  although  very  gentle 
traction  from  within  after  the  abdomen  had  been  opened  was 
sufficient  to  release  the  invagination.  The  success  of  this  case  is 
an  additional  proof  of  the  value  of  traction  upon  intestines  from 
within  in  certain  cases  of  strangulated  hernia,  or  some  other  forms 
of  intestinal  obstruction,  as  advocated  by  myself  in  a  paper  in  the 
Edinburgh  Medical  Journal  for  1873. 

A  further  observation  of  importance  in  connexion  with  operative 
interference  in  cases  of  intussusception  is,  that  reduction  of  the 
^  Treves  upon  Intestinal  Obstruction. 

EBINBURGH   MED.    JOURN.,    VOL.    XXXIV. — NO.    IX.  5   F 


778  PHOFESSOK    T.    AXNA.NDALK    ON    A    CASE    UK  [.MARCH 

invagination  is  in  the  majority  of  instances  more  easily  accom- 
plished when  the  operation  is  performed  during  the  early  stages  of 
the  condition  ;  and  Mr  Treves^  has  shown  in  his  tables  of  statistics 
that  the  easier  the  reduction  the  less  the  mortality.  When 
the  reduction  is  easy,  the  mortality  being  30  per  cent.  ;  and  when 
difficult  or  impossible,  91-3  per  cent.  An  additional  advantage  of 
an  early  operation  is  that,  in  the  majority  of  cases,  a  limited 
abdominal  incision,  with  a  limited  amount  of  interference  with  the 
abdominal  contents,  will  be  sufficient  to  relieve  the  condition. 

Case. — J.  G.,  a  male  child,  set.  3,  was  admitted  into  the  Edin- 
burgh Royal  Sick  Children's  Hospital  upon  the  27th  of  September 
1886,  under  the  care  of  Dr  Underhill,  who  has  kindly  given  me 
the  following  notes  of  the  history  and  progress  of  the  case  previous 
to  my  connexion  with  it. 

Two  days  before  admission  to  the  hospital  the  child  had  suffered 
from  pain  in  the  abdomen  with  vomiting,  which  symptoms  occurred 
quite  suddenly  and  without  any  known  cause.  It  was  also  noticed 
that  several  ounces  of  blood  were  passed  per  rectum,  some  of  which 
was  in  the  form  of  clots.  When  admitted  the  patient's  general  con- 
dition was  good,  and  the  abdomen  was  not  much  distended,  and  was 
not  painful  upon  pressure;  but  upon  the  left  side,  towards  the  lumbar 
region,  an  elongated  swelling  about  three  inches  in  length  and  two 
in  width  was  felt.  This  swelling,  which  much  resembled  in  form 
a  sausage,  was  not  painful  upon  pressure,  but  it  was  very  distinct. 
An  examination  by  the  rectum  discovered  a  rounded  mass,  which 
could  be  pushed  up  by  the  finger,  but  at  once  descended  when  the 
finger  was  withdrawn.  The  condition  was  diagnosed  to  be  one  of 
intussusception,  and  the  treatment  suggested  and  at  once  carried 
out  was  small  doses  of  opium  internally,  and  an  attempt,  under 
the  influence  of  chloroform,  to  push  back  the  tumour  in  the  rectum 
by  the  introduction  of  a  bougie,  so  as  to  reduce  the  invagination. 
This  having  failed,  enemata  of  warm  water  were  tried,  but  without 
any  good  result.  On  the  early  morning  of  the  28th  the  patient 
still  continued  to  vomit,  and  dark-coloured  mucus  was  passed  by 
the  rectum.  The  intestinal  obstruction  being  complete,  and  not 
having  been  relieved  by  the  careful  treatment  referred  to,  I  was 
asked,  as  consulting  surgeon  to  the  hospital,  to  see  the  patient,  and 
Dr  Underhill  and  myself  were  both  of  opinion  that  the  time  had 
come  for  operative  interference  as  the  only  means  of  relieving  the 
condition. 

Accordingly,  on  the  forenoon  of  the  same  day  I  opened  the 
abdomen  by  a  central  incision  about  2  inches  in  length.  When 
the  peritoneal  cavity  was  opened  into  several  coils  of  dilated  small 
intestine  first  showed  at  the  wound,  and  these  having  been  pushed 
aside  and  the  finger  introduced,  a  pear-shaped  tumour,  about  4 
inches  long,  was  felt  in  the  left  lumbar  region.     This  tumour  was 

1  Loc.  cit. 


1889.]  ACUTE  INTUSSUSCEPTION   IN   A   CHILD.  779 

laid  hold  of  with  the  finger  and  drawn  towards  the  wound ;  but  in 
doing  so  it  somewhat  suddenly  dispersed,  and  about  8  inches  of 
collapsed,  wrinkled,  and  sodden-looking  small  intestine  presented, 
and  it  was  quite  evident  that  the  comparatively  gentle  traction 
exercised  upon  the  small  intestine  had  relieved  the  invagination 
and  taken  away  the  cause  of  obstruction.  Immediately  after  the 
operation  wind  was  passed  freely  by  the  rectum,  proving  that  the 
obstruction  had  been  relieved,  and  from  this  date  the  patient's 
progress  was  excellent.  Upon  the  30th  the  bowels  were  freely 
moved.  On  the  13th  of  October  he  suffered  from  severe  ab- 
dominal pain,  and  his  pulse  became  weak,  and  in  the  evening  he 
had  some  vomiting  ;  but  a  little  simple  medical  treatment  relieved 
the  symptoms,  and  on  the  loth  he  was  quite  well  again.  On  the 
17th  he  was  able  to  leave  his  bed,  and  upon  the  21st  he  was  walk- 
ing in  the  ward.  He  was  discharged  quite  well  upon  the  28th  of 
October. 


n.-NOTE    ON   A   CASE    OF    ELEPHANTIASIS   ARABUM. 

By  R.  W.  Fblkin,  M.D.,  etc.,  Lecturer  on  Diseases  of  the  Tropics  and 
Climatology,  Edinburgh. 

{Read  before  the  Medico- Chirurgical  Society  of  Edinburgh,  \&th  January  1889.) 

I  AM  induced  to  bring  this  case  under  the  notice  of  the  Fellows 
of  this  Society  for  three  reasons — firstly,  because  elephantiasis  is 
rarely  seen  in  this  country ;  secondly,  because  the  case  presented 
various  peculiarities ;  and,  lastly,  because  the  treatment  resulted 
in  an,  at  any  rate,  apparent  cure. 

On  the  14th  of  July  1888  I  was  asked  to  see  an  unmarried  lady, 
a  Eurasian.  Her  age  was  33,  her  height  5  feet  2  inches,  and  her 
weight  11  stones  4|  lbs.  She  was  born  in  India,  and  had  resided 
there  most  of  her  life.  It  was  only  with  considerable  difficulty 
that  I  could  obtain  any  details  from  the  patient  as  to  her  previous 
history  or  the  commencement  of  her  ailment,  so  that  I  am  not 
able  to  give  many  particulars  which  would  have  made  the  case 
more  complete.  She  had  never  seen  a  doctor  professionally  in  her 
life  before,  and  greatly  objected  to  doctors,  but  I  managed  to 
ascertain  that  when  a  child  she  had  not  been  able  to  walk  properly. 
She  could  give  no  reason  for  this,  but  she  explained  her  horror  of 
doctors  by  the  fact,  that  one  of  her  earliest  recollections  was  that 
of  a  lady  constantly  threatening  to  take  her  to  see  one  if  she  did 
not  try  to  walk  better.  She  said  she  had  always  enjoyed  good 
health,  with  the  exception  of  suffering  now  and  then  from  inter- 
mittent fever.  She  had  led  an  active  life,  and  had  apparently 
undergone  considerable  exertion.  Up  to  the  beginning  of  1887 
her  appetite  had  always  been  good,  but  she  had  been  remarkably 
thin.  After  a  rather  severe  attack  of  fever  early  in  1887  she 
noticed  that  she  commenced  to  increase  in  size,  and  that  her  appe- 


780  DK  It.  vv.  felkin's  kote  on  a  [march 

tite  M'as  capricious.  She  took  a  great  dislike  to  fish,  and  always 
vomited  after  eating  it.  She  had  also  occasional  attacks  of  nausea 
and  vomiting  with  headaches.  Every  now  and  then  her  occupa- 
tion became  rather  tedious  to  her,  and  she  sometimes  felt  as  if  she 
could  hardly  keep  up.  In  September  1887,  as  she  felt  gradually 
growing  worse,  she  decided  to  leave  India  for  a  time ;  and  for  some 
unknown  reason  she  was  weighed  before  starting  on  her  journey, 
and  felt  surprised  to  find  that  she  weighed  9  stones  8  lbs.  Tlie 
voyage  home  seems  to  have  done  her  good,  for  when  she  landed  in 
England  she  felt  better  than  she  had  done  for  some  time  previously, 
and  this  improvement  in  her  feelings  continued  for  two  or  three 
months.  She  noticed,  however,  that  she  still  increased  in  size,  and 
that  her  skin  was  at  times  itchy  and  very  irritable.  Her  limbs, 
too,  felt  painful  and  sore,  more  so  than  they  had  done  in  India. 
During  the  spring  of  1888  she  was  very  busily  employed,  walking 
about  a  great  deal ;  in  fact,  she  told  me  that  she  was  more  or  less 
on  her  feet  from  nine  in  the  morning  till  ten  at  night.  In  June 
1888  she  felt  quite  unable  to  continue  her  exertions.  Her  arms 
and  legs  felt  heavy  and  powerless,  her  appetite  became  very  bad, 
and  she  felt  dull,  low-spirited,  and  miserable.  Her  food,  too, 
frequently  disagreed  with  her.  At  the  beginning  of  July  she 
decided  to  take  a  few  weeks'  rest,  and  she  then  came  under  my 
care. 

On  examining  the  patient,  I  found  her  to  be  rather  nervous 
Her  tongue  was  slightly  coated  with  a  brownish-yellow  fur ;  her 
pulse  was  104,  full,  and  almost  bounding  in  character ;  her  tem- 
perature was  100° ;  respiration,  24.  Her  heart  and  lungs  were 
apparently  quite  healthy ;  her  liver  was  slightly  enlarged,  the  area 
of  dulness  being  5^  inches  in  the  mammary  line  ;  the  spleen  was 
markedly  enlarged,  and  extended  to  within  3|  inches  of  the 
umbilicus.  On  examining  her  integumentary  system,  I  found 
that  a  remarkable  hypertrophy  had  taken  place  ;  this  hypertrophy 
affected  the  whole  of  the  body  with  the  exception  of  the  head  and 
neck,  the  forearms  and  hands,  the  legs  below  the  knees  and  the 
feet,  also  the  anterior  aspect  of  the  trunk  from  3  inches  below  the 
clavicles  to  the  umbilicus,  and  the  posterior  aspect  of  the  body 
between  the  scapulae  and  underneath  them.  A  reference  to  the 
woodcuts,  in  which  the  affected  parts  are  shaded,  will  make  the 
extent  of  the  disease  clear.  (These  diagrams  are  not  intended  to 
show  the  increase  in  the  size  of  the  limbs.)  The  upper  arm 
measured  36^  cm.  in  circumference  at  its  thickest  part  on  the  right 
side,  and  nearly  36  on  the  left ;  the  thigh  on  the  right  side  at 
its  middle  third  measured  71  cm.,  and  nearly  the  same  on  the 
left ;  the  calf  on  the  right  leg  measured  35  cm.  in  circumference 
at  its  thickest  part,  and  that  of  the  left  leg  the  same.  There  was 
distinctly  less  hypertrophied  tissue  upon  the  shoulders  and  beneath 
the  scapulae,  and  a  deep  groove  separated  the  masses  of  hyper- 
trophied tissue  over  the  scapulae. 


( 


I  L'i 


■'*^.. 


..^jX*" 


Or      FELKIN'8     CASE     OF      ELEPHANTIASIS. 
(£efcrre  TrexxtnienJL,) 


1889.] 


CASE    OF   ELEPHANTIASIS   ARABUM. 


781 


There  was  very  marked  hypertrophied  tissue  in  the  lumbar 
region  and  over  the  lower  part  of  the  abdomen  below  the  um- 
bilicus ;  in  fact,  it  might  almost  be  described  as  a  girdle  of  hyper- 


36J  cm.  before 
Treatment. 
25  cm.  after  Treatment. 


71  cm.  before  Treatment. 
54  cm.  after  Treatment. 


35  cm 


trophied  tissue,  which  sank  down  several  inches  when  the  patient 
was  in  the  erect  position.  I  was,  unfortunately,  unable  to  obtain 
any  more  detailed  measurements,  and  I  much  regret  that  it  was 
impossible  to  persuade  the  patient  to  consent  to  a  proper  photo- 
graph being  taken  of  her  remarkable  condition.  I  reproduce, 
however,  two  instantaneous  photographs,  which  may  serve  to  give 
some  idea  of  her  condition  after  a  week's  treatment  and  her  state 
shortly  before  she  left  my  care. 

The  skin  in  the  regions  I  have  above  mentioned  was  darkly  pig- 
mented, and  formed  a  distinct  contrast  to  my  patient's  natural  com- 
plexion ;  it  was  rough,  having  somewhat  the  appearance  of  the  rind 
of  a  boiled  orange  ;  it  was  tense,  and  appeared  to  be  bound  down  to 
the  subcutaneous  tissue ;  this  was  especially  the  case  in  regard  to 
the  upper  arms,  the  two  masses  of  tissue  situated  below  each 
clavicle,  and  those  over  the  scapulae,  but  in  the  other  regions  of 
the  body  the  mass  of  tissue  had  a  certain  amount  of  movement ; 
for  instance,  when  the  patient  was  in  the  erect  position,  the  masses 
of  hypertrophied  tissue  which  encircled  the  thighs  descended, 
especially  in  front,  where  they  completely  overlapped  the  patellae. 
On  palpation,  one  experienced  the  sense  of  dense,  brawny,  slightly 


782  Du  E.  w.  felkin's  note  on  a  [makch 

elastic  hardness ;  the  skin  did  not  pit  on  pressure,  or  hardly  so, 
but  it  was  slightly  painful  to  the  touch.  In  many  places,  espe- 
cially over  the  buttocks,  it  was  distinctly  nodulated,  and  presented 
a  most  typical  elephantoid  appearance,  which  appearance  was  less 
marked  in  the  upper  part  of  the  body.  The  glands  in  both  axillae 
and  in  both  groins  were  enlarged ;  in  the  natural  folds  of  the  body 
there  was  a  slight  exanthematous  eruption.  I  examined  the  blood 
and  the  urine  frequently  during  the  progress  of  the  case,  and  also 
punctured  the  tissue  in  various  parts  of  the  body,  as  I  thought 
that  at  first  I  might  have  to  deal  with  a  lymphoid  variety  of  ele- 
phantiasis ;  no  lymph,  however,  could  be  obtained.  The  amount 
of  urine  passed  varied  from  50  to  70  ounces  in  the  twenty-four 
hours;  the  sp,  gr,  varied  from  1012  to  1025.  With  the  exception 
of  some  albumen  which  was  present  in  the  urine  for  the  first  three 
weeks,  nothing  abnormal  could  be  detected.  On  one  occasion,  it 
is  true,  I  thought  I  saw  a  few  ova  of  the  Filaria  sanguinis  hominis, 
but  repeated  microscopical  examination  gave  no  confirmation.  The 
microscopical  examination  of  the  blood  gave  no  results,  and  this 
Dr  Edington  kindly  confirmed ;  he  also  kindly  endeavoured  to 
obtain  cultivations  from  the  blood,  but  without  success. 
Menstruation  was  irregular  and  slightly  painful. 

Treatment. 

Absolute  rest  was  enjoined,  and  the  patient  had  a  hot  bath 
almost  every  day.  A  moderate  amount  of  bland  food  was  ordered, 
consisting  chiefly  of  milk  (the  patient  could  never  eat  fish ;  I  tried 
it  on  several  occasions,  but  it  always  caused  nausea  and  vomiting). 
The  patient  was  regularly  massaged.  Commencing  with  half-an- 
hour  a  day,  the  rubbing  was  subsequently  increased  to  an  hour 
and  a  half,  and  the  constant  current  battery  was  applied  for  twenty 
minutes  each  day.  A  mixture  was  prescribed  containing  quinine, 
arsenic,  iron,  and  strychnine,  and  the  bowels  were  regulated  by 
the  frequent  administration  of  aperients. 

The  progress  of  the  case  was  in  every  way  satisfactory ;  with 
the  exception  of  a  slight  rise  in  the  temperature  for  six  days  after 
the  massage  had  been  commenced,  all  went  well.  The  patient 
complained  of  nothing  excepting  the  battery  and  the  pain  that  the 
massage  gave  her  during  the  first  three  weeks.  The  massage  and 
battery  were  discontinued  about  the  10th  of  September,  by  which 
time  the  skin  had  become  normal  in  character, — in  fact,  had 
returned  to  its  usual  condition,  and  all  tension  and  hard  feeling 
had  disappeared.  A  remarkable  diminution  had  taken  place  in 
the  circumference  of  the  limbs,  the  circumference  of  the  upper 
arms  having  been  reduced  to  25  cm.  and  the  middle  third  of  the 
thighs  only  measuring  54  cm.  in  circumference.  The  mass  of 
hypertrophied  tissue  encircling  the  body  had  quite  disappeared. 
The  patient  stated  that  she  felt  quite  well,  buoyant,  and  fit  for 
work.     She  could  walk  with  ease  and  comfort,  and  by  the  middle 


/■■ 

/  . 

'I 


\    I 


I 


jSS'lfSta--- 


DR      FELKIN'8     case     OF      ELEPHANTIASIS. 
fAffer  Treatrrtjerit) 


1889.]  CASE   OF   ELEPHANTIASIS   ARABUM.  783 

of  October  she  was  apparently  quite  restored  to  health,  and  has 
continued  so  to  the  present  time.  I  should  perhaps  mention  that 
for  a  week  or  two  after  her  prolonged  rest  the  patient  suffered 
from  slight  swelling  of  the  feet  and  ankles.  This  condition,  how- 
ever, completely  disappeared. 

Bemarks  on  the  Case. 

Probably  the  most  remarkable  fact  in  the  whole  case  was  the 
situation  of  the  elephantoid  growth.     I  have  never  seen  a  case 
like  it  before,  and  the  one  which  most  nearly  resembles  it  is  that 
of  the  "  elephant  man  "  which  was  published  in  the  British  Medical 
Journal,  Dec.  11, 1886,  p.  1188.    In  looking  over  the  literature  of  the 
subject,  I  find  very  few  instances  of  elephantiasis  occurring,  except 
in  the  feet,  legs,  scrotum,  penis,  and  the  female  genital  organs.     Dr 
Green  of  Serampore  refers  to  a  very  exceptional  case  in  which  the 
whole  body  of  a  Hindoo  gentleman  was  affected,  except  the  thorax 
and  head.     Dr  Rose  of  Faridpore  mentions  it  as  sometimes  affect- 
ing the  abdomen.     Sub-assistant  Surgeon  G-hosal  of  Bankipore  has 
met  with  cases  affecting  the  forearm  and  breasts  of  females,  and 
in  this  connexion  he  has  formed  the  opinion  that  elephantiasis  is 
connected  with  either  the  arrival  of  puberty  or  its  decline,  especi- 
ally as  the  genital  organs  are  so  often  attacked,  and  the  disease, 
both  in    men  and  women,  often  undergoes   montlily  variations, 
and  in  women  this  variation  usually  coincides  with  menstrua- 
tion, and  is  often  preceded  by  some  derangement  of  that  function. 
Baboo  J.  Chunder  Roy  of  Lucknow  agrees  with  this  opinion.     My 
patient,  it  will  be  noticed,  suffered  from  painful  and  irregular 
menstruation,  but  I  could  gain  no  exact  information  with  respect 
to  this  subject.     Dr  G.  A.  Turner,  when  at  Samoa,  reported  that 
in  43  cases  the  female  breast  was  attacked  seven  times.    Surgeon  F. 
M'Calmont  reported  that  the  face  was  affected  next  in  frequency 
to  the  left  leg,  but  I  can  find  no  statistics  to  bear  out  this  state- 
ment.    A  case  is  reported  from  Dr  Kerr's  hospital.  Canton,  of  a 
man,  aged  25,  who  was  attacked  by  elephantiasis  on  the  face.    His 
lips  and  nose  were  greatly  hypertrophied,  and  tumours  were  formed 
under  the  eyes.     I  may  also  notice  that  Mr  Saville  mentions 
in  1873  that  at  the  Society  Islands  he  met  with  one  case  in  which  a 
woman  had  one  breast  attacked  and  enormously  enlarged.    He  says, 
too,  that  elephantiasis  "  sometimes  attacks  the  buttocks.     Only  one 
case  of  this  kind  has  come  under  my  notice.     The  sufferer  is  a 
woman  of  about  50  years  of  age ;  the  enlargement  is  a  ponderous 
mass,  preventing  almost  any  act  of  locomotion.     Both  buttocks  are 
attacked."     Chevers  noticed  that  the  forearms  were  attacked  in 
cases  near  Orissa,  and  says  that  the  hands  are  often  affected  in 
Travancore ;  and  Surgeon  Ghosal  refers  to  the  disease  as  affecting 
the  leg  and  arm  in  rare  cases,  and  as  sometimes  extending  to  other 
limits.     Liveing  only  met  with  one  case  in  which  first  one  arm  and 


784      NOTE  ON  A  CASE  OF  ELEPHANTIASIS  ARABUM.    [mARCII 

tlien  the  other  was  affected,  both  below  the  elbow;  they  were 
greatly  enlarged.  In  Central  Africa,  where  I  saw  a  considerable 
number  of  cases  of  elephantiasis,  I  never  met  with  it  excepting  as 
affecting  the  legs  or  genital  organs. 

Another  point  of  interest  in  my  case  was  the  effect  which  eating 
fish  had  upon  my  patient.  One  of  the  theories  of  the  production 
of  elephantiasis  is  that  the  disease  is  at  times  produced  by  a  fish 
diet.  Clarke  of  Sierra  Leone  laid  great  stress  on  this  cause  ;  but, 
on  the  other  hand,  Waring  says  that  in  Travancore,  where  the 
disease  is  so  prevalent,  only  11  out  of  800  cases  were  fishermen; 
and  that  at  a  fishing  village  near  Trivandrum,  containing  150 
families  who  lived  almost  entirely  on  fish,  no  case  of  elephantiasis 
was  seen.  Now  my  patient's  aversion  to  fish  occurred  shortly  after 
the  growth  began,  and  it  was  probably  only  a  coincidence,  but  I 
think  it  worth  mentioning. 

The  next  point  to  which  I  will  call  attention  is  one  of  con- 
siderable interest,  namely,  that  during  the  whole  course  of  the 
disease  my  patient  suffered  so  little  from  fever.  Waring  states 
that  there  was  a  distinct  history  of  fever  in  9911  per  cent,  of  the 
cases  he  examined,  and  he  shows  from  his  statistics  that  when 
fever  ceases  to  recur,  increase  in  the  hypertropliy  of  the  tissue 
ceases  also ;  but  there  are  undoubtedly  cases  of  elephantiasis  on 
record  in  which  fever  has  been  totally  absent  throughout  the  whole 
progress  of  the  disease.  There  is,  too,  some  difference  of  opinion 
as  to  whether  the  fever  which  is  present  in  most  cases  is  due  to  a 
distinct  fever  or  to  malaria.  Sir  Joseph  Fayrer  says,  "  Even  when, 
as  occasionally  happens,  fever  has  ceased  to  recur,  there  may  be  a 
gradual  but  slow  and  painless  increase  in  the  hypertrophy."  This 
is  what  happened  in  my  case,  for  practically  no  fever  was  experi- 
enced and  no  pain  was  suffered  by  my  patient,  only  a  feeling  of 
weight  and  discomfort.  As  a  rule,  in  cases  of  elephantiasis  the 
spleen  is  not  enlarged,  or  at  any  rate  only  slightly,  I  think  that 
in  my  case  the  splenic  enlargement  was  due  to  progressive  malarial 
cachexia,  and  not  to  the  elephantiasis. 

All  authorities  agree  that  change  of  climate  is  the  most  potent 
remedy  for  elephantiasis,  often  arresting  its  progress  in  early 
stages,  but  here  once  more  my  case  illustrates  an  exception  to  the 
rule.  My  patient  only  weighed  9  stones  8  lbs.  when  she  left  India; 
when  I  first  saw  her  she  weighed  11  stones  4|  lbs.,  so  that  in  her 
case  the  change  of  climate  was  not  beneficial  to  the  disease. 

The  last  point  which  I  will  notice  is  the  effect  of  the  treatment 
on  the  disease.  I  confess  I  was  greatly  surprised  at  it.  I  had 
hoped  for  a  possible  arrest  of  the  growth  and  probably  a  slight 
diminution  in  size,  but  that  so  rapid  a  disappearance  should  have 
occurred  greatly  gratified  me.  The  lady  has  insisted  upon  return- 
ing to  India,  and  it  will  be  interesting  to  know  whether  a  return 
of  the  malady  takes  place. 


1889.]  NOTES   ON   A   CASE   OF   FEMORAL   HERNIA.  785 


III.— NOTES  ON  A  CASE  OF  FEMOEAL  HERNIA  ACCIDENT- 
ALLY MET  WITH  IN  THE  DEAD  SUBJECT. 

By  W.  Scott  Lang,  M.D.,  F.E.C.S.E. 

The  body  was  that  of  an  old  man,  rather  emaciated.  Before 
commencing  the  dissection,  it  was  noticed  that  the  left  half  of  the 
scrotum  was  imperfectly  developed,  and  hardly  any  appearance  of 
testicle  could  be  observed.  Careful  palpation  revealed  a  small 
nodule  towards  the  upper  part  of  the  left  side  of  the  scrotum,  and 
within  about  half  an  inch  of  the  external  abdominal  ring.  Tliis 
afterwards  turned  out  to  be  a  very  small  testicle  incompletely  de- 
veloped and  only  partly  descended.  The  right  half  of  the  scrotum 
was  normal,  and  contained  a  testicle,  not  large,  but  apparently 
normal. 

This  external  examination  revealed  a  state  of  matters  corre- 
sponding to  several  of  the  cases  described  by  Mr  Curling  in  his 
work  on  Diseases  of  the  Testis. 

The  superficial  dissection  of  the  left  thigh  showed  nothing 
abnormal,  and  after  having  removed  the  skin  and  some  fascia  and 
the  superficial  lymphatic  glands  of  the  thigh,  there  was  no  evident 
appearance  of  liernia  or  tumour.  This  is  mentioned  in  order  to 
illustrate  a  point  well  known  to  clinicians.  Had  tliere  been  any 
appearance  of  tumour  in  the  groin  or  thigh,  no  doubt  it  would 
have  been  observed  when  dissection  was  being  carried  on  in  that 
region.  With  regard  to  this  point,  Hesselbach  states  that  femoral 
hernia,  although  not  common  in  men,  is  more  frequent  tlian  is 
generally  supposed,  and  often  overlooked  on  account  of  its  being 
very  small. 

Dissection  of  the  abdominal  wall  was  being  commenced,  and  on 
first  attempting  to  distend  the  abdominal  cavity  with  air,  there 
was  still  no  appearance  of  hernia ;  but  on  a  second  and  more 
energetic  attempt,  a  tumour  the  size  of  a  pigeon's  egg,  or  rather 
larger,  appeared  in  the  left  thigh  below  Poupart's  ligament,  and  on 
the  inner  side  of  the  femoral  vessels.  The  swelling  measured 
If  inches  by  1^  inch,  and  was  evidently  a  portion  of  peritoneum 
(a  sac,  in  fact)  distended  with  air. 

It  might  have  been  supposed  that  this  hernia  had  been  produced 
by  powerfully  plying  the  bellows  in  order  to  distend  the  abdominal 
cavity  with  air,  but  such  was  not  the  case.  The  tumour  was, 
indeed,  a  femoral  hernia  filled  with  air,  but  instead  of  having  been 
produced  post-mortem,  it  had  evidently  existed  for  a  long  time. 
In  fact,  the  writer  is  inclined  to  suggest  the  possibility  of  its 
having  been  a  congenital  femoral  hernia,  for  reasons  which  will  be 
afterwards  adduced.  At  any  rate,  it  had  evidently  existed  for  a 
long  time,  and  the  patient  had  been  unconscious  of  its  existence. 

On  opening  the  abdominal  cavity,  it  was  found  that  the  great 
omentum  was  rather  long,  and  the  lower  margin  of  it  was  gathered 

EDINBURGH    MED.    JOURN.,    VOL.    XXXIV. — NO.    IX.  5  G 


786  DIl   W.   SCOTT   LANG'S   NOTES   ON  [MAKCII 

together  and  matted  into  a  cylindrical  piece  about  the  size  and 
shape  of  one's  little  finger,  Tliis  had  doubtless  been  a  hernia 
of  part  of  the  omentum,  and  the  finger-like  portion  had  been  filling 
the  pouch  of  peritoneum  in  the  thigh. 

In  the  attempts  to  inflate  the  abdomen  the  nozzle  of  the  bellows 
had  pulled  out  the  contents  of  the  sac  by  having  come  into  con- 
tact with  the  transverse  colon  and  omentum,  and  thereafter  the 
sac  became  distended  with  air,  and  the  tumour  appeared  in  the 
thigh  as  already  described.  The  specimen  is  still  in  the  writer's 
possession,  and  shows  a  portion  of  transverse  colon  with  omentum 
proceeding  downwards  from  it.  The  herniated  portion  of  omentum 
measures  in  length  2  inches. 

The  hernial  pouch  was  then  examined  from  inside  the  abdominal 
cavity.  The  little  linger  could  be  introduced  into  it,  and  it  was 
found  to  pass  under  Poupart's  ligament  and  internal  to  the  deep 
epigastric  artery.  The  obliterated  hypogastric  artery  of  the  right  side 
was  visible,  and  the  fold  of  peritoneum  round  it  was  well  marked. 
On  the  left  side,  however,  the  obliterated  hypogastric  artery  was 
indistinctly  seen,  and  it  had  evidently  been  interfered  with  and 
diverted  from  its  ordinary  course  by  the  pouch  of  peritoneum  de- 
scending into  the  thigh.  The  opening  into  the  hernial  pouch  is 
nearly  circular,  and  the  under  lip  of  it  is  folded  upon  itself  to  some 
extent,  and  consequently  thickened. 

Dissection  of  the  thigh  was  then  proceeded  with,  and  the  sac 
was  carefully  exposed.  The  layers  covering  it  were  as  usually 
described,  but  the  deeper  layers  (fascia  transversalis  and  fascia 
propria  of  Sir  Astley  Cooper)  could  be  split  up  into  almost  any 
number  of  very  delicate  layers  before  reaching  the  sac  of 
peritoneum. 

The  testicles  were  next  examined.  The  right  testicle  w^as  fairly 
in  the  scrotum,  and  measured  fully  1  inch  in  length.  It  was 
situated  about  3  inches  from  the  external  abdominal  ring.  The 
left  measured  less  than  a  quarter  of  an  inch,  and  was  situated  about 
half  an  inch  outside  the  external  abdominal  ring.  In  fact,  it  was 
not  easily  recognised  to  be  a  testicle,  and  the  structures  forming  the 
spermatic  cord  were  incompletely  formed  in  a  corresponding  degree. 

The  interest  in  the  case  was  increased  upon  subsequently  making 
the  discovery  that  the  kidney  was  horse- slioe  shaped.  The  con- 
necting portion  measured  fully  1  inch  in  breadth,  and  evidently 
consisted  of  true  kidney  substance.  It  passed  across  in  front  of  the 
abdominal  aorta  and  inferior  vena  cava,  and  on  a  level  with  the 
upper  border  of  the  body  of  the  fourth  lumbar  vertebra. 

The  ureters,  as  usual  in  such  cases,  came  out  from  the  upper 
portions  on  each  side,  and  passed  in  front  of  the  connecting  or 
transverse  portion  of  kidney  substance.  This  transverse  portion 
of  renal  tissue  passed  underneath  the  inferior  mesenteric  artery, 
and  the  said  artery  lay  in  close  relation  with  its  anterior  surface. 
The  connecting  renal  tissue,  so  to  speak,  lay  in  a  cleft,  having 


1889.]  A    CASE    OF   FExMOIiAL    IlEHNIA.  787 

behind  it  the  abdominal  aorta,  and  in  front  of  it  the  inferior 
mesenteric  artery. 

At  a  point  on  the  abdominal  aorta,  helow  the  origin  of  the 
inferior  mesenteric  artery,  there  arose  three  good -sized  branches 
(renal  arteries),  and  they  entered  the  "connecting"  renal  tissue 
directly.  These  arteries  varied  from  three-quarters  of  an  inch  to 
an  inch  and  a  quarter  in  length.  There  were  two  renal  arteries 
and  corresponding  veins  at  about  the  usual  level.  The  inferior 
mesenteric  artery  came  off  from  the  antero-dexter  aspect  of  the 
abdominal  aorta,  and  passed  down  on  the  right  side  of  the  sacral 
promontory. 

There  was  a  meso  rectum  attached  rather  to  the  right  of  the 
middle  of  the  sacrum,  and  corresponding  in  position  to  the  inferior 
mesenteric  artery.  The  horse-shoe  kidney  is  described,  not  as 
having  any  direct  bearing  on  the  question  of  hernia,  but  on  account 
of  its  being  associated  with  a  testicle  imperfectly  descended. 

There  is  a  unique  case  described  by  Mr  Gr.  St  Hilaire,  in  which 
he  states — "  The  scrotum  was  bifid,  the  two  suprarenal  capsules, 
the  two  kidneys,  and  the  two  testicles  were  within  the  abdomen, 
where  they  were  united  in  the  middle  line.  The  spermatic  vessels, 
vesiculse  seminalis,  and  vasa  deferentia  were  present." 

In  the  subject  at  present  under  review,  the  kidneys  were 
"  united  in  the  middle  line,"  and  the  left  testicle  was  incompletely 
descended.  It  suggests  itself  as  being  a  sort  of  gradation  between 
Mr  St  Hilaire's  case  and  the  normal  state  of  things. 

Questions  regarding  the  descent  of  the  testicle,  although  usually 
only  discussed  when  inguinal  hernia  is  under  consideration,  deserve 
notice  also  with  regard  to  their  possible  bearing  upon  the  patho- 
logy of  femoral  hernia.  This  should  be  at  once  apparent  when  it 
is  pointed  out  that  the  testicle  itself  may  pass  under  Poupart's 
ligament  and  appear  in  the  thigh,  and  that  the  testicle  is  preceded 
"  by  some  time"  in  its  descent  by  a  process  of  peritoneum  (Quain). 
This  at  once  suggests  the  possibility  of  a  congenital  femoral  hernia, 
and  further  arguments  in  support  of  this  hypothesis  will  be 
adduced  in  a  subsequent  paper. 

Although  femoral  hernia  cannot  be  considered  rare,  there  are 
not  many  recorded  cases  of  post-mortem  examination  and  dissec- 
tion. Morgagni  expressly  states  that  he  never  met  w'ith  a  crural 
hernia  in  the  dead  body  of  any  male  subject.  Arnaud  also  states 
that  he  never  had  an  opportunity  of  dissecting  such. 


788        Du  JOHNSON  Symington's  contiubution  to  the    [march 

IV.— A   CONTRIBUTION   TO   THE    NORMAL    ANATOMY    OF 
THE  FEMALE  PELVIC  FLOOR. 

By  Johnson  Symington,  M.D.,  F.R.S.E.,  Lecturer  on  Anatomy,  Minto 
House,  Edinburgh, 

{Read  before  the  Obstetrical  Society  of  Edinburgh,  9th  January  1889.) 

Teie  importance  and  variety  of  the  functions  performed  by  the 
pelvic  tioor,  no  less  than  the  frequency  with  which  its  structures 
are  impaired,  render  an  accurate  knowledge  of  its  anatomy  and 
physiology  an  essential  preliminary  to  the  scientific  study  of 
gyniecology  and  obstetrics ;  yet,  with  the  exception  of  Dr  Berry 
Hart,^  few  writers  have  devoted  much  time  to  the  investigation 
of  its  general  topography,  or  of  the  changes  that  may  occur 
in  the  position  of  its  different  parts  under  various  physiological 
conditions. 

One  of  the  most  obvious  functions  of  the  pelvic  floor  is  that  of 
supporting  the  superimposed  viscera.  This  is  especially  the  case 
in  the  human  subject,  for  the  weight  of  the  abdominal  viscera, 
which  in  most  mammals  is  largely  borne  by  the  ventral  wall  of 
the  abdomen,  tends  to  become  transferred,  with  the  assumption  of 
the  erect  posture,  from  this  wall  to  the  pelvic  floor.  The  pelvic 
floor  is  not,  however,  merely  an  organ  of  support,  since  it  contains 
canals  by  means  of  which  the  urinary,  genital,  and  alimentary 
tracts  communicate  with  the  exterior,  and  through  which  the 
contents  of  the  bladder,  uterus,  and  rectum  can  pass  to  the 
exterior.  In  the  process  of  parturition  the  floor  must  be  capable 
of  very  great  displacement,  as  the  diameters  of  the  foetal  head  are 
nearly  equal  to  those  of  the  pelvic  outlet. 

In  this  paper  the  term  "pelvic  floor"  includes  not  merely  its 
muscular  diaphragm,  but  the  whole  of  the  soft  structures  that  close 
the  inferior  outlet  of  the  female  pelvis.  It  is  composed  of  skin, 
mucous  membrane,  fascite,  muscles,  and  fat,  arranged  in  such  a 
manner  as  to  form  a  thick  and  tolerably  compact  mass.  There  is 
no  difficulty  in  defining  the  lower  limit  of  the  pelvic  floor,  as  all 
will  readily  admit  that  this  is  formed  by  the  skin.  With  the 
upper  boundary  the  case  is  different,  since  here  the  difficulty  is  to 
determine  whether  certain  organs,  which  are  connected  with  the 
pelvic  floor,  ought  to  be  considered  as  entering  into  its  formation 
or  as  resting  upon  it.  Thus  Dr  Berry  Hart  describes  the  bladder 
as  forming  an  important  part  of  the  anterior  portion  of  the  pelvic 
floor,  and  Dr  Henry  C.  Coe,  in  his  article  on  "  The  Anatomy  of  the 
Female  Pelvic  Organs,"  in  the  American  System  of  Gt/ncecology, 
vol.  i.  p.  222,  published  in  1887,  stated  that,  properly  speaking,  the 
term  includes  botli  bladder  and  rectum. 

1  (a.)  The  Structural  Anatomy  of  the  Female  Pelvic  Floor.  Edinburgh,  1880  ; 
and  (6.)  The  Topographical  and  Sectional  Anatomy  of  the  Female  Pelvis.  Edin- 
burgh, 1885. 


1889.]         NORMAL   ANATOMY    OF   THE   FEMALK   PELVIC   FLOOK.  789 

For  various  reasons  I  feel  compelled  to  differ  from  these  authors, 
and  to  consider  that  the  rectum  and  bladder,  like  the  uterus,  should 
not  be  regarded  as  parts  of  the  pelvic  floor,  but  as  organs  resting 
upon  it.  Dr  Hart  has  specially  emphasized  the  fact,  that  the 
pelvic  floor  forms  a  compact  mass,  which  is  traversed  by  certain 
"clefts"  or  "faults,"  the  walls  of  these  clefts  being  normally  in 
contact,  so  that  they  bound  merely  potential  spaces.  I  quite  agree 
with  this  view,  but  would  add,  that  although  these  clefts  may  open 
up  for  the  passage  of  material  through  them,  they  do  not  act  as 
reservoirs  like  the  cavities  of  the  bladder,  uterus,  and  rectum.  If 
we  regard  the  bladder  as  constituting  a  part  of  the  pelvic  floor, 
then  we  must  admit  that  the  floor  rises  up  into  the  abdomen  when 
the  bladder  is  distended. 

In  addition  to  the  ordinary  methods  of  dissecting,  the  pelvic 
floor  has  been  studied  mainly  from  vertical  mesial  sections  of  the 
pelvis.  Such  specimens,  although  of  undoubted  value,  afford  only 
a  limited  view  of  the  floor,  and  require  to  be  supplemented  by 
transverse  sections  in  order  to  ascertain  its  lateral  relations.  With 
the  exception,  however,  of  those  by  Dr  Hart,  very  few  drawings  of 
such  sections  have  been  published.  Even  the  sections  given  in 
Halt's  more  recent  work'  are  not  well  adapted  for  showing  the 
thickness  and  connexions  of  the  anterior  part  of  the  floor,  for  his 
transverse  sections  were  made  in  the  direction  of  the  axis  of  the 
inlet  of  the  pelvis,  and  consequently  divided  the  pelvic  floor  very 
obliquely.  Thus  all  the  drawings  he  gives  of  axial  coronal  sections 
pass  through  the  lower  part  of  the  floor  behind  the  anus  (see 
plates  v.,  viii.,  ix.,  and  x.)  In  order  to  obviate  this  objection, 
I  made  a  series  of  transverse  sections  of  a  female  pelvis  in  which 
the  floor  was  divided  at  about  a  right  angle  to  its  upper  and  under 
surfaces.  In  this  paper  I  propose  to  describe  the  specimens  pre- 
pared in  this  way,  and  then  to  consider  the  general  structure  of  the 
pelvic  floor. 

The  subject  upon  which  the  sections  were  made  was  a  female, 
aged  54,  who  died  from  cardiac  and  pulmonary  disease.  The 
abdominal  and  pelvic  organs  were  healthy.  The  entire  body  was 
frozen ;  and  after  the  abdomen  had  been  divided  at  about  the  level 
of  the  umbilicus,  and  the  thighs  in  their  upper  thirds,  the  pelvis 
was  cut  into  five  slabs.  The  direction  and  position  of  the  cuts 
will  readily  be  understood  from  an  examination  of  Fig.  1,  which 
represents  a  construction  of  a  mesial  section  of  this  pelvis.  The 
four  straight  lines  crossing  the  figure  from  above  downwards 
and  backwards  indicate  the  position  of  the  sections  in  the 
mesial  plane,  and  the  five  slabs  into  which  the  pelvis  was 
divided  by  these  sections  are  numbered  from  before  backwards 
1,  2,  3,  4,  5. 

The  first  section  is  seen  to  have  passed  through  the  bladder, 
urethra,    pudendal    cleft,   and    labia    majora    and    minora.     The 

1  Op.  cit.,  1  (b). 


790  DK  JOHNSON   SYMINGTONS   CONTRIBUTION   TO   TIIK      [MAHCII 

urethra  was  divided  somewhat  obliquely  about  the  middle  of  its 
length.  The  section  is  ^  of  an  inch  behind  the  external  orifice 
of  the  urethra,  and  about  the  same  distance  in  front  of  its  vesical 
opening.  It  is  farther  from  the  symphysis  pubis  above  than  below, 
being  1^  inches  behind  its  upper  border,  and  fths  of  an  inch  behind 
its  lower  end.  The  section  is  a  trifle  farther  back  on  the  right 
side  than  on  the  left.  On  the  right  side  it  goes  through  the 
anterior  superior  and  inferior  iliac  spines,  while  on  the  left  side  it  is 
immediately  in  front  of  these  processes. 


Fia.l.—SP,  Symphysis  pubis;  S,  First  piece  of  sacrum;  o,  Anterior  urethral  wall;  J,  Urethro- 
vaginal septum;  c,  Perineal  body;  d,  Ano-coccygeal  body;  u,  Urethra;  v,  Vagina;  u  u,  Uterus. 

The  structures  forming  the  pelvic  floor  and  the  lateral  walls  of 
the  true  pelvis  in  the  plane  of  this  section  are  shown  in  Fig.  2, 
which  is  a  view  of  the  posterior  aspect  of  No.  1  slab  after  the 
removal  of  some  coils  of  the  intestines,  of  the  bladder  with  its 
peritoneal  reflections,  and  of  the  retro-pubic  fat.  The  portion  of 
the  bladder  in  this  slab  was  connected  with  the  pelvic  wall  by  the 
reflections  of  the  peritoneum.  It  is  important  to  observe  that 
below  these  folds  of  the  peritoneum  the  bladder  was  attached  to 
the  back  of  the  pubes  and  also  to  the  pelvic  fascia  merely  by  loose 


1889.] 


NORMAL   ANATOMY   OF   THE   FEMALE   PELVIC   FLOOR. 


791 


cellular  tissue  and  fat,  so  that  it  could  easily  be  separated  from 
them  with  the  handle  of  a  knife. 

The  lateral  walls  of  the  true  pelvis  are  divided  opposite 
the  obturator  foramina.  Above  the  foramen,  on  each  side,  the 
pelvic  brim  is  cut  at  the  outer  extremity  of  the  ascending  ramus 
of  the  pubis ;  while,  below  the  foramen,  the  pubic  arch  is  divided 
near  the  upper  end  of  the  ascending  ramus  of  the  ischium.  The 
lateral  wall  is  completed  by  the  obturator  membrane,  covered  on 
its  inner  aspect  by  the  obturator  internus  muscle  and  the  obturator 
or  parietal  layer  of  the  pelvic  fascia. 

The  part  of  the  pelvic  floor  exposed  in  the  plane  of  this  section 
is  about  2  inches  in  thickness,  and  the  floor  maintains  this  depth 
as  far  forwards  as  the  pubic  symphysis.  The  lower  half  of  tlie 
floor  is  divided  into  two  lateral  halves  by  a  deep  mesial  cleft,  which 


Fig.  2. — P.A.,  Pubic  arch;  O.I.,  Obturator  internus  muscle;  O.E.,  Obturator  externus  muscle  ; 
A  L.,  Anterior  layer  of  triangular  ligament;  U.,  Urethra;  V.C,  Vulval  cleft;  B.,  Vestibular 
bulb. 

divides  above  into  two  short  limbs.  The  upper  half  is  traversed 
by  the  urethra,  which  appears  as  a  transverse  slit  about  I  of  an 
inch  in  length. 

The  upper  boundary  of  the  portion  of  the  pelvic  floor  seen  in 
this  slab  is  formed  by  a  layer  of  the  pelvic  fascia,  which  is  attached 
at  the  sides  to  the  obturator  fasciae,  and  in  front  to  the  back  of  the 
pubes.  Its  upper  surface  is  pierced  just  behind  the  pubic  sym- 
physis by  a  vein,  but  otherwise  it  forms  a  continuous  layer.  A 
short  distance  on  either  side  of  the  middle  line  the  floor  is  thick- 
ened by  fibres  going  from  the  pubis  backwards  to  the  bladder. 
These  fibres  form  the  anterior  true  ligaments  of  the  bladder  ; 
beneath  them  there  are  a  few  muscular  fibres  having  the  same 
direction  and  connexions.  From  this  layer  of  pelvic  fascia  down- 
wards to  the  anterior  layer  of  the  triangular  ligament  and  the 


792  Dlt   JOHNSON   SYMINGTON'S   CONTRIBUTION   TO   TIIP]      [mAKCH 

vestibu]ar  bulbs  there  is  a  firm  mass  of  tissue,  composed  of  part 
of  the  origins  of  the  levatores  ani,  of  the  posterior  layer  of  the 
triangular  ligament,  and  of  the  muscular  fibres  surrounding  the 
urethra.  If,  in  this  specimen,  wliich  I  now  sliow  you,  the  thumb 
be  passed  into  the  pudendal  cleft  and  the  forefinger  above  the 
pelvic  fascia,  and  the  tissue  between  them  grasped  by  these  digits, 
it  will  be  at  once  evident  that  this  part  of  the  pelvic  floor  is  firndy 
attached  both  in  front  and  at  the  sides. 

On  each  side  of  the  pudendal  cleft  there  is  a  large  mass  of  fat, 
which  extends  upwards  between  the  bulbo-cavernosus  muscle 
covering  the  bulb  and  the  erector  clitoridis  muscle  lying  super- 
ficial to  its  crus.  This  fat  is  continuous  with  that  on  the  inner 
side  of  the  thighs.  Below,  the  floor  is  bounded  by  tlie  skin  of  the 
labia  majora.  In  this  specimen  they  are  somewliat  atrophied, 
allowing  the  labia  minora  to  be  visible  (vulva  hians). 

I  have  given  a  detailed  description  of  this  slab,  as  I  consider  it 
demonstrates  a  very  different  condition  of  the  anterior  part  of  the 
pelvic  floor  from  that  described  by  Dr  Hart.  I  have  already  ex- 
pressed my  dissent  from  the  view  of  Hart,  that  the  bladder  forms 
part  of  the  pelvic  floor.  You  are,  of  course,  aware  that  he  divides 
this  floor  into  two  parts,  which  he  designates  the  pubic  and  sacral 
segments.  The  pubic  segment  is  described  as  having  a  loose 
attachment  in  front.  I  quite  admit  tliat  this  is  the  case  with  the 
bladder,  but  it  is  not  so  with  the  structures  lying  below  the 
bladder.  Indeed,  in  my  opinion,  the  anterior  part  of  the  pelvic 
floor  is  composed  of  as  firm  tissue,  and  is  connected  as  strongly 
with  the  anterior  part  of  the  pelvic  wall,  as  is  the  sacral  segment 
with  the  sacrum  and  coccyx. 

The  second  section  is  about  an  inch  posterior  to  the  one  just 
described.  It  passes  through  the  bladder,  vagina,  perineal  body, 
and  fat  of  ischio-rectal  fossse.  In  this  section  the  transverse 
diameter  of  the  inlet  of  the  bony  pelvis  is  4|  inches,  and  that  of 
the  outlet,  which  is  bounded  by  tlie  ischial  tuberosities,  is  3| 
inches.  The  obturator  muscles  lying  internal  to  the  osseous  lateral 
walls  diminishes  considerably  the  transverse  diameter  of  the  pelvic 
cavity,  so  that  opposite  the  thickest  parts  of  these  muscles  it 
measures  only  about  2|  inches.  The  base  of  the  bladder  is  divided 
about  midway  between  the  openings  of  the  ureters  and  the  in- 
ternal orifice  of  the  urethra.  This  part  of  the  bladder  lies  upon 
the  anterior  wall  of  the  vagina,  with  which,  however,  it  is  only 
loosely  connected.  The  vagina  appears  as  a  transverse  slit  about 
11  inches  in  length. 

It  will  be  remembered  that  in  No.  1  section  the  pudendal  or 
vulval  cleft  was  situated  in  the  middle  line,  and  was  about  an 
inch  in  depth.  At  its  upper  part  this  mesial  cleft  divided  into 
two  limbs  about  fths  of  an  inch  long.  In  order  to  show  the 
relation  between  the  mesial  pudendal  and  the  transverse  vaginal 
clefts,  the  second  slab,  after  the  removal  of  its  bony  walls,  was 


1889.] 


NORMAL   ANATOMY    OF   THE    FEMALE    PELVIC   FLOOR. 


793 


embedded  in  collodion  and  then  cut  into  a  number  of  thin  slices.' 
The  series  of  sections  obtained  in  this  way  show  that  as  the  vulval 
cleft  passes  backwards  towards  the  vagina  its  two  limbs  increase 
in  length  and  become  more  horizontal.  Ultimately  the  vertical 
cleft  is  bounded  posteriorly  by  the  perineal  body,  and  its  two 
limbs  become  continuous  with  the  vagina. 


^^„  r  ,1  #  ^Y^-XfKi-y 


Murray 


Fio.  3. — B.,  Brim  of  true  pelvis;  I.T.,  Ischial  tuberosity;  O.I.,  Obturator  internus;  O.F., 
Obturator  fascia;  L.A.,  Levator  ani;  P.B.,  Perineal  body;  A.W.,  Anterior  wall  of  vagina; 
Bl.,  Trigone  of  bladder. 

Fig.  3  represents  a  view  from  the  front  of  the  third  slab.  From 
this  drawing  it  will  be  seen  that  the  pelvic  floor,  in  the  plane  of 
this  section,  is  formed  by  a  part  of  the  pelvic  fascia,  the  levatores 
ani,  the  perineal  body,  and  the  fat  of  the  ischio-rectal  fossae  with 
the  integument  below. 

In  the  first  section  (see  Fig.  2)  we  saw  that  the  pelvic  fascia 
passed  uninterruptedly  across  the  pelvis  from  one  side  to  the 
other,  and  formed  a  well-defined  upper  boundary  to  the  pelvic 
floor.  This  is  not  the  case  in  this  section,  since  the  direct  con- 
tinuity of  the  fasciae  on  the  two  sides  is  interrupted  by  the 
presence  of  the  bladder  and  vagina.  The  layer  of  fascia  attached 
externally  to  the  parietal  or  obturator  fascia,  and  going  downwards 
and  inwards  on  the  inner  aspect  of  the  levator  ani,  becomes  con- 
nected with  the  bladder  at  the  side  of  its  base,  and  is  often  called 
the  lateral  true  ligament  of  the  bladder.    This  ligament  is  connected 

^  I  am  indebted  to  Dr  Woodliead  for  permission  to  make  these  sections  in 
the  Laboratory  of  the  College  of  Physicians. 

EDINBURGH   MED.   JOURN.,    VOL.  XXXIV.— NO.    IX.  5  H 


794        Du  joHNSOxV  Symington's  contribution  to  the    [maucii 

with  one  layer  of  fascia  running  upwards  and  outwards  on  the 
side  of  the  bladder,  and  with  another,  which  goes  downwards  and 
inwards  on  the  inner  side  of  the  levator  ani,  passing  close  to  the 
lateral  angle  of  the  vagina  and  becoming  lost  in  the  perineal  body. 
There  is  no  distinct  sheet  of  fascia  passing  inwards  between  the 
bladder  and  vagina,  but  these  organs  are  connected  by  loose 
cellular  tissue.  The  posterior  vaginal  wall  is  closely  adlierent  to 
and  may  be  said  to  form  part  of  the  perineal  body.  In  this  posi- 
tion I  am  inclined  to  regard  the  floor  as  bounded  above  by  the 
fascia,  covering  the  inner  aspect  of  the  levator  ani,  and  by  the 
posterior  vaginal  wall.  The  anterior  vaginal  wall  might  be 
included  in  the  floor,  still  I  prefer  to  consider  the  portions  of  the 
anterior  vaginal  wall  and  the  base  of  the  bladder  exposed  in  this 
section  as  being  immediately  above  the  floor,  but  attached  to  it  at 
the  urethro-vaginal  septum  (see  Fig.  1). 

The    third   section   is    about    half   an    inch    behind    that   just 


Pio.  4. — v.,  Vagina;  r.,  End  of  second  part  of  rectum;  t.s.,  Internal  sphincter;  «.».,  External 
sphincter;  La.,  Pubo-coccygeus  part  of  levator  ani;  o.c,  Obturator-coccygeus.  The  interval 
between  the  levator  ani  and  external  sphincter  was  less  than  that  represented  in  this  woodcut. 

described.  In  it  the  osseous  pelvis  is  cut  about  1^  inches  behind 
the  anterior  superior  iliac  spines,  just  posterior  to  the  acetabula 
and  at  the  back  part  of  the  ischial  tuberosities.  The  section 
goes  through  the  posterior  portion  of  the  bladder,  the  upper 
part  of  the  vagina,  the  termination  of  the  rectum,  and  the  whole 
length  of  the  anal  canal.  In  the  plane  of  this  section,  and 
this  was  also  the  case  in  the  second  section,  the  vesical  and 
vaginal  walls  are  connected  by  loose  cellular  tissue.  The  posterior 
vaginal  wall,  however,  instead  of  being  blended  with  the  perineal 
body,  lies  upon  and  is  separated  from  the  anterior  rectal  wall  by 


1889.] 


KOKMAL   ANATOMY   OF   THE   FEMALE   PELVIC  FLOOK. 


795 


some  adipose  tissue.  I  have  already  stated  that  I  consider  both 
tlie  bladder  and  rectum  to  be  situated  above  the  floor,  and  would 
also  add  that  the  same  is  the  case  with  the  upper  pait  of  the 
vagina.  Below  tlie  termination  of  the  rectum  the  pelvic  floor  is 
traversed  by  the  anal  canal.  I  described  the  shape  and  relations 
of  this  canal  in  a  paper  on  the  "  Eectum  and  Anus/'  which  was 
published  in  the  Journal  of  Anatomy  and  Fhysiology  ioi:  Oct.  1888. 
The  subject  may  be  briefly  referred  to  here,  as  it  involves  the 
question  of  the  relations  of  the  pelvic  floor  at  the  anus. 

Fig.  4  is  a  drawing  of  part  of  the  posterior  aspect  of  No.  3  slab, 
tliat  is  the  anterior  of  the  two  surfaces  exposed  by  the  third 
section.  The  structures  represented  are  the  vagina,  the  rectum, 
the  anal  canal,  the  sphincters  of  the  anus,  and  the  levatores  ani. 
It  will  be  seen  that  the  lateral  walls  of  the  anal  canal  are  in  con- 
tact. Tlie  muscles  lying  at  the  sides  of  this  canal  are  the  two 
sphincters  and  the  pubo-coccygeus  portion  of  the  levatores  ani. 
External  to  these  structures  the  pelvic  floor  is  formed  by  a  thin 
layer  of  muscular  fibres,  i.e.,  the  obturator-coccygeus  (Savage)  part 
of  levator  ani.  Above  these  fibres  is  a  layer  of  the  recto-vesical 
fascia,  and  below  them  the  anal  fascia  and  the  fat  of  the  ischio- 
rectal fossa. 

The  fourth  section  through  this  pelvis  is  not  parallel  with  the 
third  section,  the  slab  between  them  being  much  thicker  above 
than  below  (see  Fig.  1).  This  section  goes  through  the  first 
piece  of  the  sacrum  and  the  sacro-iliac  joints,  and  lower  down 
divides  the  ischial  spines.  It  is  posterior  to  the  ischial  tuberosities, 
but  cuts  across  the  great  sacro-sciatic  ligaments.  The  viscera 
divided  are  the  rectum  and  uterus. 


Fio.  5.— S.I.,  Spiue  of  iscliium  ;  S.S.,  Great  sacro-sciatic  ligament ;  G.M.,  Gluteus  maximus; 
L  A,  Levator  ani;  K., Rectum. 


Fig.  5  shows  a  part  of  the  anterior  aspect  of  the  fifth  slab.     The 
upper  surface  of  the  pelvic  floor  is  seen  to  be  concave  from  side  to 


79G  DU    JOIIXHOK    SVMlIvGTON'tt    CU.NTlilBUTlON    TO    TlIK      [.MARCH 

side,  and  to  extend  from  one  ischial  spine  to  the  other.  The 
rectum  rests  upon  it,  but  is  only  loosely  attached  to  it.  The 
pelvic  floor  is  liere  divisible  into  a  central  and  two  lateral  portions. 
The  central  portion  is  composed  of  the  muscles  which  in  the  previous 
section  were  found  at  the  sides  of  the  anal  canal,  viz.,  the  internal 
and  external  sphincters  of  the  anus  and  the  pubo-coccygei  portions 
of  the  levatores  ani.  The  mass  of  tissue  between  the  anal  canal 
and  the  coccyx  may  be  called  the  ano-coccygeal  body.  If  it  be 
divided  by  a  series  of  transverse  sections  passing  from  above 
downwards  and  backwards,  it  will  be  found  to  become  less 
muscular  as  the  coccyx  is  approached,  the  muscular  fibres  being 
replaced  by  fibrous  tissue  and  fat.  The  lateral  portions  of  this 
part  of  the  pelvic  floor  are  formed  mainly  by  fat.  This  fat,  how- 
ever, is  bounded  above  by  some  fibres  of  the  levator  ani  and  a 
layer  of  the  pelvic  fascia),  while  towards  its  lower  part  the  floor  is 
strengthened  by  the  gluteus  maximus  muscle.  The  relations  of 
this  muscle  to  the  posterior  part  of  the  pelvic  floor  is  well  shown 
in  plates  ix.,  x.,  and  xi.  of  Hart's  Contributions  to  the  Topo- 
graphical and  Sectional  Anatomy  of  the  Female  Pelvis. 

Most  of  the  important  points  connected  with  the  anatomy  of 
the  female  pelvic  floor  will  be  found  to  have  been  alluded  to  in 
connexion  with  the  account  of  the  series  of  sections  just  described. 
Some  of  these,  however,  have  only  been  incidentally  mentioned, 
and  will  now  be  considered  more  fully. 

In  the  mesial  plane  the  pelvic  floor  is,  as  a  rule,  about  an  inch 
thick.  At  the  sides  it  varies  in  different  situations,  but  it  is 
always  thicker  than  in  the  middle  line,  and  near  the  lateral  wall 
of  the  pelvis  is  generally  from  two  to  three  inches  in  thickness. 
Its  comparative  thinness  in  the  middle  line  is  partly  due  to  its 
upper  surface  being  generally  concave  from  side  to  side,  but  it  is 
mainly  owing  to  the  presence  of  a  median  fissure  on  the  under 
surface  extending  from  the  front  of  the  pubes,  below  the  mons 
veneris,  backwards  as  far  as  the  posterior  aspect  of  the  coccyx. 
The  lateral  walls  of  this  median  depression  are  formed  mainly  by 
skin,  and  their  degree  of  apposition  depends  largely  upon  the 
position  of  the  thighs,  whether  abducted  or  adducted.  In  front  of 
the  perineal  body  and  between  the  labia  majora  this  median  fissure 
is  known  as  the  pudendal  or  vulval  cleft,  while  behind  it  forms 
the  natal  cleft,  being  situated  between  the  two  nates.  The  vulval 
cleft  opens  below  between  the  labia  majora.  It  is  bounded  above 
in  the  middle  line  (see  Fig.  1)  by  the  glans  clitoridis  with  its  pre- 
puce, by  the  tissue  between  the  glans  and  the  orifice  of  the 
urethra,  and  by  the  lower  edge  of  the  urethro-vaginal  septum.  In 
front  of  this  septum  is  the  orifice  of  the  urethra  and  behind  it  the 
entrance  to  the  vagina.  The  posterior  boundary  is  the  anterior 
aspect  of  the  perineal  body,  the  lower  part  of  which,  on  lateral 
traction,  presents  a  transverse  fold — the  fourchette.  The  depres- 
sion above  the  fourchette  and  below  the  entrance  to  the  vagina  is 


188[».]         NORMAL  ANATOMY   OF   THE   FEMALE   PELVIC   FLOCK.  797 

known  as  the  fossa  navicularis.  On  the  lateral  walls  of  this 
fif>sure  are  the  labia  minora,  which,  beginning  in  iVont  at  the 
clitoris,  may  extend  backwards  to  the  fourchette.  The  labia 
minora  appear  to  me  to  vary,  not  only  in  their  length,  but  also  in 
the  distance  of  their  attachment  from  the  lower  opening  of  the 
vulval  cleft.  According  to  Hart,^  both  labia  majora  and  minora 
are  composed  of  skin,  and  on  the  inner  side  of  the  base  of  the 
labium  minus  is  a  white  line  indicating  the  junction  of  skin  and 
mucous  membrane,  so  that  below  this  line  the  walls  of  the  vulval 
cleft  are  formed  by  skin  and  above  it  by  mucous  membrane.  The 
part  of  the  vulval  cleft  bounded  by  mucous  membrane  corresponds 
to  what  is  olten  called  the  vestibule. 

The  lateral  walls  of  the  vulval  cleft  are  usually  in  contact  even 
when  the  thighs  are  abducted.  There  is,  however,  no  muscular 
tissue  to  maintain  them  in  apposition.  An  examination  of  the 
section  represented  in  Fig.  2  shows  that  external  to  the  integu- 
ment these  walls  are  composed  mainly  of  fat,  which,  however,  is 
ti-aversed  by  a  number  of  fibrous  and  elastic  bundles.  At  the 
sides  of  the  upper  part  of  the  cleft  the  vestibular  bulbs  intervene 
between  the  mucous  membrane  and  the  fat  (see  Fig.  2). 

In  addition  to  the  vulval  and  natal  clefts  there  are  three  slits  in 
the  pelvic  floor,  viz.,  the  urethra,  the  vagina,  and  the  anal  canal. 
The  two  former  open  below  into  the  vulval  cleft,  and  the  latter 
into  the  natal  cleft. 

The  urethra  is  a  small  transverse  fissure  which  does  not  to  any 
appreciable  extent  weaken  the  floor.  The  vagina  in  the  greater  part 
of  its  extent  is  in  the  form  of  a  transverse  slit,  so  that  its  walls  are 
anterior  and  posterior,  and  lie  in  close  apposition.  In  the  female 
pelvis,  described  in  this  paper,  the  breadth  of  the  vagina  was 
1^  inches  a  little  below  the  middle  of  its  length,  and  f  of  an 
inch  nearer  the  os  uteri  externum  it  was  a  trifle  narrower.  Its 
anterior  and  posterior  walls  are  described  as  triangular,  with  the  base 
upwards  and  the  apex  at  the  introitus.  It  must  be  remembered, 
however,  that  the  apex  is  very  blunt,  and  that  the  diminution  in 
the  transverse  diameter  of  the  vagina  near  its  lower  end  is  to  a 
great  extent  compensated  for  by  certain  foldings  of  the  vaginal 
walls  in  this  situation.  The  vaginal  slit  is  undoubtedly  the  main 
source  of  weakness  in  the  female  pelvic  floor.  Owing,  however,  to 
the  fact  that  it  passes  very  obliquely  from  below  upwards  and 
backwards,  the  general  effect  of  the  intra-abdominal  pressure  is  to 
press  its  anterior  wall  against  the  posterior  (Hart).  Only  about 
the  lower  half  of  the  vagina  is  in  the  pelvic  floor,  the  upper  portion 
being  above  the  floor. 

The  anal  canal  is  an  antero-posterior  slit  situated  between  the 
perineal  and  ano-coccygeal  bodies.  It  is  about  an  inch  in  length, 
and  cuts  the  pelvic  floor  at  nearly  a  right  angle  to  its  antero- 
posterior axis.  This  axis  in  the  posterior  part  of  the  floor  is 
^  Edin.  Med.  Journal,  September  1882. 


798        mi  JOHNSON  Symington's  contkjbution  to  thk    [makch 

diroctcMl  foiwarcls  and  downwiuds,  while  the  anus  runs  dow  iiwaids 
and  backwards.  Intia-abdoniinal  ])ressure,  therefoi'c,  will  tend  to 
open  rather  than  close  this  canal.  This  source  of  wiakncss  in  tlie 
pelvic  floor  is  compensated  for  by  the  relation  of  the  hnver  end  of 
the  rectum  to  the  anus,  and  by  the  ])resence  of  powerful  sjihincter 
muscles.  The  anal  canal  is  normally  merely  an  antero-])osterior 
slit,  while  the  lower  end  of  the  rectum  has  a  distinct  transverse 
diameter,  so  that  the  anterior  rectal  wall  or  the  contents  of  the 
lower  end  of  tlie  rectum  will  be  su])ported  by  the  tissues  at  the 
sides  of  the  canal. 

In  the  mesial  plane  the  pelvic  floor  is  formed  from  before  back- 
wards by  the  anterior  urethral  wall  and  the  tissue  connecting  it 
Avith  the  lower  jiart  of  the  pubic  symphysis,  by  the  urethro-vaginal 
septum,  by  the  perineal  body,  and  by  the  ano-coccygeal  body. 
Mesial  sections  are  not  well  adapted  i'or  displaying  the  connexions 
of  the  anterior  part  of  the  pelvic  floor  with  the  anterior  wall  of  the 
pelvis,  as  the  pubo-vesical  and  triangular  ligaments  are  not  so  well 
developed  in  the  mesial  plane  as  they  are  a  short  distance  on 
either  side  of  that  plane. 

The  upper  limit  of  the  pelvic  floor  can  easily  be  defined  and 
separated  from  the  pelvic  viscera,  both  in  front  and  behind.  Thus 
from  the  pubes  backwards  nearly  to  the  urethral  orifice  the  floor  is 
bounded  above  by  the  pelvic  fascia,  which  is  separated  from  the 
bladder  by  loose  fat  and  areolar  tissue.  Again,  from  the  coccyx 
forwards,  nearly  as  far  as  the  anal  canal,  the  rectum  is  separated 
from  the  floor  by  loose  cellular  tissue  and  fat.  Between  these 
points,  however,  the  attachment  of  the  pelvic  viscera  to  the  floor  is 
more  intimate.  Thus  in  a  mesial  section  the  anterior  urethral  wall 
is  seen  to  be  continuous  with  the  anterior  wall  of  the  bladder. 
Behind  the  urethra  the  firm  mass  of  tissue  forming  the  urethro- 
vaginal septum  is  continuous  above  with  the  base  of  the  bladder 
and  with  tlie  upper  part  of  the  anterior  vaginal  wall.  The  perineal 
body  in  a  similar  manner  is  connected  above  with  the  upper  part 
of  the  posterior  vaginal  wall  and  the  anterior  rectal  wall,  while 
behind  the  anal  canal  the  posterior  wall  of  the  lower  end  of  the 
rectum  is  continuous  with  the  anterior  part  of  the  ano-coccygeal 
body.  Between  the  lateral  wall  of  the  pelvis  and  the  bladder, 
vagina,  and  rectum,  the  pelvic  floor  is  limited  above  by  the  layer  of 
pelvic  fascia  stretching  from  the  side  wall  of  the  pelvis  to  the 
above-mentioned  viscera. 

The  most  important  muscles  in  the  pelvic  floor  are  the  levatores 
ani,  but  the  accounts  of  their  arrangement  and  functions  will  be 
found  to  differ  greatly.  Savage^  divides  each  levator  into  two 
portions,  which  he  names  the  pubo-coccygeus  and  the  obturator- 
coccygeus.  I  believe  that  these  two  portions  differ  not  only  in 
their  arrangement  but  also  in  their  function.     The  pubo-coccygeus 

1  The  Sim/ery,  Surgical  Pathology,  and  Surgical  Anatomy  of  the  Female  Pelvic 
Organs.     5th  edition.     London,  1882. 


1889.]         NORMAL   ANATOMY    OF   THP:   FEMALE   PELVIC   FLOOR.  799 

arises  from  tlie  posterior  surface  of  the  pubis  and  the  posterior 
layer  of  the  triangular  ligament.  Its  fibres  pass  backwards  on 
the  side  of  the  lower  part  of  the  vagina,  and  on  the  side  of  the 
anal  canal  to  the  last  two  pieces  of  the  coccyx.  A  few  of  its 
innermost  fibres  turn  inwards  in  the  perineal  body  in  front  of  the 
internal  sphincter  of  the  anus.  Behind  the  anus,  and  in  front  of 
the  coccyx,  there  is  a  partial  blending  of  fibres  of  opposite  sides  in 
the  middle  line. 

Tiie  pubo-coccygei  act  as  sphincters  of  the  lower  part  of  the 
vagina  and  of  the  anal  canal,  but  they  cannot  compress  the  upper 
part  of  the  vagina  nor  the  rectum.  They  also  draw  upwards  and 
forwards  the  perineal  body  and  coccyx. 

The  obturator-coccygeus  consists  of  those  fibres  of  the  levator 
ani  that  arise  from  the  pelvic  fascia  between  the  pubis  and  the 
ischial  spine.  Its  fibres  run  backwards  and  inwards  to  the 
coccyx.  These  fibres  have  no  direct  action  upon  any  of  the  pelvic 
viscera.  They  constitute  a  thin  layer  of  fibres,  which,  in  addition 
to  raising  the  coccyx,  can  elevate  the  pelvic  floor  a  little  after  it 
has  been  depressed. 

The  sphincters  of  the  anus  are  shown  in  Fig.  4,  and  do  not  call 
for  any  special  notice. 

The  bulbo-cavernosus  seen  in  Fig.  2  is  sometimes  called  the 
sphincter  vaginae.  Taking  its  fixed  point  in  front  it  may  have  a 
slight  influence  in  drawing  forwards  the  perineal  body,  but  its 
main  function  is  evidently  the  compression  of  the  vestibular  bulb, 
and  it  certainly  does  not  exert  any  appreciable  influence  upon  the 
lumen  of  the  vagina. 

An  examination  of  the  series  of  coronal  sections  already  described 
will  show  that  fat  enters  very  largely  into  the  construction  of  the 
pelvic  floor,  for  in  all  of  them  a  large  wedge-shaped  mass  of  fat  is 
seen  on  each  side.  The  apex  of  the  wedge  is  directed  upwards 
towards  the  pelvis,  and  the  base  is  connected  with  the  skin 
forming  the  inferior  boundary  of  the  pelvic  floor.  These  masses 
of  fat  evidently  act  as  elastic  cushions  supporting  the  structures 
internal  to  them,  but  capable  of  displacement  and  compression  in 
order  to  allow  of  the  opening  up  of  the  slits  in  the  pelvic  floor. 

When  the  thigh  is  adducted,  a  groove  is  found  extending  from 
before  backwards  between  the  labium  majus  and  the  inner  side  of 
the  thigh.  Except  in  thin  subjects,  the  bottom  of  this  groove  is 
directed  upwards  and  outwards,  so  that  the  labium  majus  rests 
partly  upon  the  inner  side  of  the  thigh,  which  thus  assists  in 
closing  the  vulval  cleft  and  supporting  the  pelvic  floor. 

The  special  purpose  of  this  communication  has  been  to  state  the 
results  of  my  own  investigations  on  the  normal  topographical 
anatomy  of  the  female  pelvic  floor,  but  before  closing  I  would 
briefly  compare  them  with  those  of  Dr  Berry  Hart  on  this  subject. 
In  his  work  on  The  Structural  Anatomy  of  the  Female  Pelvic 
Floor,  published  in    1880,  he  proposed  a  division  of   the  pelvic 


800 


DK   JOHNSON   SYMINGTON'S   CONTUIBUTION    TO   THE      [maUCH 


floor  into  two  parts,  viz.,  an  anterior  or  pubic  segment,  and  a 
posterior  or  sacral  segment,  separated  from  one  another  by  the 
vaginal  cleft.  He  held  that  this  division  was  based  on  differences 
in  their  anatomical  structure  and  function,  and  he  compared  them 
as  follows  (p.  12)  : — 

"  The  pubic  segment  of  the  pelvic  floor  is  thus  loose  in  texture, 
has  only  a  loose  bony  attachment  anteriorly,  and  will  evidently 
permit  of  mobility  in  an  up  or  down  direction." 

"  The  sacral  segment  of  the  pelvic  floor  is  strong  in  structure, 
has  a  strong  dovetailed  attachment  to  the  sacrum,  and  is  only 
movable  downwards,  with,  of  course,  a  recoil  upwards,  when  it 
revolves  round  the  sacrum  and  coccyx  as  a  centre." 


Fig.  6.— Drawing  reduced  by  photography  from  Table  C  in  Braune's  Atl&s— Die  Lage  dea  Uterus 
und  Foetus  am  Ende  der  Schwangerschaft  (Habt). 

I  consider  this  division  of  the  floor  to  be  a  very  convenient  one, 
but  my  own  investigations  have  failed  to  convince  me  of  the 
existence  of  the  marked  contrast  between  the  two  segments 
described  by  Dr  Hart.  I  should  say  that  the  texture  of  the 
pubic  segment  is  on  the  whole  as  compact,  if  not  more  so,  than 
that  of  the  sacral.  Then,  again,  with  regard  to  their  attachments, 
the  pubic  segment  is  undoubtedly  firmly  attached  to  the  pubic 
arch,  while  I  have  failed  to  find  any  strong  dovetailed  attachment 
of  the  floor  to  the  sacrum  and  coccyx. 

It  should  be  noticed  that  Dr  Hart  puts  the  bladder  in  the  pubic 
segment.     This  organ  is  undoubtedly  loosely  connected  with  the 


1889.]         NORMAL   ANATOMY   OF  THE   FEMALE   PELVIC   FLOOR.  801 

anterior  wall  of  the  pelvis,  and  his  description  would  be  correct 
were  the  bladder  the  only  structure  forming  the  pubic  segment. 
I  do  not  consider  it  a  part  of  the  floor,  but  even  though  it  be 
regarded  as  such,  Dr  Hart's  description  is  not  applicable  to  the 
part  of  the  pubic  segment  situated  below  the  bladder. 

Dr  Hart  has  further  endeavoured  to  show  that  during  labour, 
when  the  pelvic  floor  is  opened  up  for  the  passage  of  the  child 
through  it,  the  pubic  segment  is  drawn  upwards,  and  the  sacral 
pushed  downwards  and  backwards.  He  compares  the  process  to 
passing  through  two  swinging  bank-doors.  "  One  half  is  pulled 
towards  the  passenger,  the  other  is  pulled  from  him."  In  a 
Society  such  as  this,  I  am  reluctant  to  venture  an  opinion  on  a 
subject  regarding  which  I  have  no  clinical  experience.  As, 
however,  Dr  Hart  bases  his  very  ingenious  theory  largely  upon 
Braune's  section  of  a  woman  in  labour,  I  may  be  permitted  to 
state  that  Braune's  drawing  does  not  appear  to  me  to  warrant  the 
deductions  Hart  has  drawn  from  it.  The  plate  (see  Fig.  6)  seems 
to  me  to  show  that  the  pubic  segment  (/)  is  pushed  downwards  and 
forwards  under  the  pubic  arch.  The  urethra  may  be  somewhat 
increased  in  length,  but  it  lies  mainly  below  the  pubic  arch.  The 
bladder  is  the  only  part  of  Hart's  pubic  segment  that  is  not 
depressed.  It  is  partly  flattened  up  against  the  symphysis,  while 
a  small  portion  {ej  lies  above  it. 

In  a  future  communication  I  hope  to  have  the  opportunity  of 
bringing  before  this  Society  the  results  of  some  investigations 
upon  the  pathological  anatomy  of  the  pelvic  floor. 


v.— AN  EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 

STOKES  RESPIRATION. 

By  G.  A.  Gibson,  M.D. 

(Continued  from  page  692.) 

BiOT^  carefully  describes  this  type  of  breathing  as  it  occurred 
in  the  case  of  a  patient  suffering  from  aortic  and  mitral  disease, 
and  for  the  first  time  publishes  tracings  of  the  pulse  and  respira- 
tion. The  pulse  was  relatively  more  frequent  during  the  pause 
than  during  the  breathing,  and  the  tension  fell  during  the  former 
phase.  He  mentions  several  of  the  writings  which  preceded  his 
work,  and  criticises  the  rival  theories  of  Traube  and  Filehne.  He 
especially  refers  to  the  lessened  arterial  pressure  during  the 
apnoea,  shown  by  his  tracings,  as  being  antagonistic  to  the  theory 
of  Filehne,  which  requires  stimulation  of  the  vaso-motor  centre, 
and  consequent  contraction  of  the  arteries  during  that  phase.  He 
mentions  that  the  pupil  was  contracted  during  the  pause,  and 

^  Gontrihition  a  V^tiide  dxi  pMnomlne  respiratoire  de  Cheyne-Stokes.  Lyon, 
Riotor,  1876. 

EDINBURGH   MED.   JOURN.,   VOL.    SXXIV. — NO.   II.  5  I 


802  DR   G.   A.    GIBSON   ON   THE  [MARCH 

states  that  chloral  produced  considerable  benefit  to  the  patient. 
In  summing  up  he  points  out  that  the  theory  of  Filehne  is  not 
applicable  to  all  cases,  but  he  declines,  for  the  present,  to  formulate 
another.  As  a  postscript  he  mentions  the  pauses  of  the  respira- 
tion in  meningitis,  which  he  describes  as  being  entirely  irregular 
and  sighing  in  character.  He  will  not  admit  that  such  cerebral 
breathing  belongs  to  the  type  of  Cheyne-Stokes  respiration,  although 
it  is  related  to  it. 

Pepper  1  calls  attention  to  the  significance  of  Cheyne-Stokes  re- 
spiration in  cases  of  tubercular  meningitis,  and  records  two  such 
instances  in  an  interesting  paper  on  the  subject.  In  both  the  cases 
which  he  describes  there  were  variations  in  the  condition  of  the 
circulation  coincident  with  the  changes  in  the  state  of  the  respira- 
tion, the  pulse  becoming  less  frequent  during  the  cessation  of  the 
respiratory  movements.  The  author  regards  the  phenomenon  as 
being  caused  by  "  a  paresis  or  state  of  impaired  sensibility  and 
activity  of  the  nervous  centres  of  respiration,"  in  which  they 
cease  to  respond  to  the  small  quantity  of  carbonic  acid  in  the 
blood  when  it  has  been  oxygenated  by  active  respiratory  move- 
ments. It  is  w^orthy  of  note  that  Pepper  refers  to  Begbie's 
mention  of  the  case  of  Philiscus,  described  by  Hippocrates, 
alluded  to  in  the  early  part  of  this  article,  and  it  is  permissible  to 
quote  his  words.  "  On  reading  the  description  of  the  case,"  he 
says,  "  which  may  probably  have  been  one  of  acute  nephritis,  with 
uraemia,  in  the  original  and  in  Daremberg's  translation,  however,  I 
cannot  see  that  anything  more  is  intended  than  the  infrequent, 
deep  breathing  with  long  intervals,  which  is  so  often  met  with  in 
states  of  partial  or  complete  coma." 

Hein^  begins  an  elaborate  contribution  to  the  subject  by 
stating  that  all  arrests  of  respiration  are  not  to  be  regarded  as 
instances  of  Cheyne-Stokes  respiration.  He  says  that  such 
irregular  interferences  with  the  usual  rhythm  are  common  in 
infants  and  children.  He  mentions  that  he  has  observed  six 
cases  of  true  Cheyne-Stokes  breathing — two  in  patients  suffering 
from  Bright's  disease,  one  of  whom  had  a  fatty  heart,  and  the 
other  oedema  glottidis  and  pneumonia ;  one  in  a  patient  who  had 
induced  fatty  degeneration  of  the  heart  through  alcoholism ;  and 
three  in  patients  dying  of  tubercular  meningitis.  He  gives  full 
details  of  a  seventh  case.  The  patient  on  this  last  occasion  was 
an  old  lady,  who  had  suffered  for  a  long  time  from  bedsores  with 
profuse  suppuration,  in  consequence  of  being  confined  to  bed  after 
a  severe  bruise  to  her  left  hip,  and  in  whose  case  Hein  diagnosed 
fatty  degeneration  of  the  heart.  During  the  course  of  the  illness 
Cheyne-Stokes  breathing  made  its  appearance,  and,  as  it  remained 
for  five  weeks,  the  author  of  this  paper  was  able  to  make  careful 
observations   in   regard  to  its   phenomena.      He  calls   attention 

1  Philadelphia  Medical  Times,  vol.  vi.  p.  416,  1876. 

2  Wiener  medizinische  Wochenschrift,  xxvii.  Jahrgang,  S.  317  und  341,  1877. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES  RESPIEA.TION.  803 

particularly  to  the  condition  of  the  consciousness.  He  noticed, 
when  she  was  sitting  up,  that  during  the  respiratory  pause,  which 
took  place  with  the  thorax  in  the  position  of  expiration,  the  head 
sunk  forward  as  if  in  sleep,  while  with  the  commencing  respira- 
tions she  raised  it  again  like  one  awaking  from  slumber.  During 
the  pause  the  eyes  were  shut  as  in  sleep;  she  could  be  roused  from 
this  condition  by  loud  speaking,  showed  her  tongue  when  asked 
to  do  so,  swallowed  a  mouthful  of  water,  and  could  even  speak  a 
word  or  two,  but  the  senses  were  dull ;  with  the  first  superficial 
respirations,  however,  the  consciousness  returned,  she  opened 
her  eyes  and  spoke  spontaneously,  complaining  particularly  of 
her  breathlessness.  During  the  pause  she  could  not  be  induced 
to  breathe.  At  the  end  of  the  pause  slight  twitchings  about  the 
mouth  were  to  be  seen,  but  otherwise  there  were  no  involuntary 
muscular  movements.  No  pupillary  changes  corresponding  to 
the  varying  phases  of  the  breathing  could  be  determined,  but 
this  point  was  rendered  difficult  by  the  fact  that  there  was 
a  cataract  in  the  left  eye,  while  the  lens  and  a  piece  of  the  iris 
had  been  removed  from  the  right  eye  in  a  previous  cataract 
operation. 

Hein  points  out  that  the  fluctuations  in  the  condition  of  the  con- 
sciousness must  be  accounted  for  by  the  same  causes  as  those  which 
give  rise  to  the  respiratory  phenomena,  and  asserts  that  this  gives 
a  new  position  from  which  to  consider  the  condition  of  the  medulla 
oblongata.  He  allows  that  changes  in  the  state  of  the  consciousness 
have  previously  been  noted  in  this  condition,  but  shows  that  no 
one  has  called  attention  to  the  simultaneous  return  of  the  con- 
sciousness and  the  respiration,  and  holds  that  this  fact  is  of  such 
importance  that  he  can  only  reject  every  theory  that  does  not 
account  for  the  return  of  the  cerebral  and  medullary  functions  at 
the  same  time.  He  points  out  that  the  relation  between  the  irrita- 
bility of  the  respiratory  centre  and  the  degree  of  respiratory  stimu- 
lation must  undergo  a  periodic  change. 

Criticising  the  rival  theories  of  Traube  and  Filehne,  he  remarks, 
in  regard  to  the  latter,  that  he  has  observed  in  a  child,  aged  seven 
months,  a  fall  of  the  blood-pressure  in  the  great  fontanelle  at  the 
time  of  the  return  of  the  breathing,  and  states,  on  the  authority  of 
Mayer  and  Friedrich,  that  amyl  nitrite  directly  stimulates  the 
respiratory  centre  and  may  thus  cause  regular  breathing.  He 
shows  that  the  theory  of  Traube  cannot  account  for  the  simul- 
taneous return  of  consciousness  and  respiration,  while  his  own 
observation  is  in  direct  opposition  to  the  hypothesis  of  Filehne, 
for  it  does  not  agree  with  his  experience  that  in  a  patient  suffering 
from  cardiac  weakness  and  its  consequences,  the  dulness  of  the 
sensorium  would  be  removed  by  means  of  a  sudden  contraction  of 
the  arteries  and  anaemia  of  the  brain.  Such  an  effect  would  sooner 
be  produced  by  an  arterial  hypersemia  through  paralysis  of  the 
vessels,  but  such  an  explanation  is  negatived  by  the  fact  that  the 


804  DR  G.   A.   GIBSON  ON  THE  [MARCH 

fulness  of  the  vessels  of  the  face  and  neck  remained  equal  during  both 
phases.  He  points  out  further  that  the  variations  of  the  conscious- 
ness and  respiration  must  have  the  same  cause,  and  shows  that 
in  all  his  cases  cyanosis  was  present,  which,  although  arising  from 
different  conditions,  has  the  same  result.  Just  as  is  the  case  with 
the  vitality  in  general,  so  in  the  medulla  oblongata  tlie  irritability  is 
lessened,  and  hence  interruptions  in  the  breathing  are  caused ;  it  is 
open  to  question  whether  these  breaks  may  not  cause  an  influence 
on  the  circulation,  so  that  what  was  a  consequence  may  in  other 
conditions  be  a  cause.  With  a  normal  circulation  such  an  effect 
he  holds  to  be  impossible,  as  Cheyne-Stokes  respiration  may  be 
imitated  by  the  hour  without  any  noticeable  modification  of  the 
circulation.  It  is  otherwise,  however,  when  the  blood-stream  is 
retarded  and  oxygenation  reduced,  for  if  interruptions  to  the 
respiration  take  place,  the  functions  are  alternately  increased  and 
diminished,  and  such  effects  are  shown  in  the  medulla  oblongata 
through  variations  in  its  irritability. 

The  blood  which  has  been  arterialized  during  the  respiratory 
period  reaches  the  capillaries  in  greatest  part  at  the  beginning  of 
the  pause,  at  which  time  the  circulation  which  had  been  quickened 
by  the  breathing  becomes  slower,  while  the  tissue  change  is  most 
active.  The  result  is  that  the  irritability  of  the  medulla  is  again 
increased  and  the  breathing  begins.  By  means  of  the  passage,  during 
the  breathing  period,  of  the  blood  which  has  become  venous  during 
the  pause,  the  tissue- change  for  the  vitality  necessary  to  the 
functional  activity  of  the  organ  cannot  be  supported,  the  oxygen 
in  the  tissues  is  consumed  without  adequate  compensation,  and 
the  irritability  of  the  respiratory  centre  is  lessened  and  suspended. 
It  is  again  restored  after  arterialized  blood  has  coursed  through 
the  vessels  of  the  medulla  and  promoted  internal  respiration,  as 
occurs  at  the  end  of  the  pause.  That  the  irritability  shows  a  stage 
of  increase  and  a  stage  of  decrease  is  due  to  the  fact  that  the 
alternation  in  the  conditions  of  the  circulation  and  diffusion  is 
gradual,  not  sudden.  From  the  analogous  conditions  of  the  brain 
and  medulla  it  is  to  be  concluded  that  the  respiratory  nerve  centre 
does  not  simply  undergo  a  change  in  the  degree  of  stimulation,  but 
a  periodic  alteration  of  its  own  condition. 

Hein  is  of  opinion  that,  although  this  theory  of  a  periodic 
activity  of  the  brain  and  medulla  caused  by  variations  in  the 
amount  of  the  tissue  change  is  only  hypothetical,  it  yet  explains 
what  he  thinks  cannot  be  otherwise  accounted  for.  He  holds 
that  the  frequent  occurrence  of  the  phenomenon  in  unconscious 
persons  does  not  oppose  his  theory,  for  in  such  cases  the  periodic 
demand  of  tissue  change  may  be  so  insignificant  that,  although  it 
is  in  a  position  to  affect  the  activity  of  the  respiratory  centre,  it 
may  not  be  able  to  influence  the  functions  of  the  brain. 

Carrer '  describes  the  case  of  a  man,  aged  60,  who  died  of  renal 
*  Gazeta  medica  Italiana,  Provincie  Venete,  tomo  xx.  p.  403,  1877. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  805 

disease  and  cardiac  failure.  Cheyne-Stokes  respiration  appeared 
after  the  patient  had  presented  various  head  symptoms  for  some 
days,  and  remained  long  enough  to  allow  the  author  to  make  a 
number  of  interesting  observations.  He  mentions  that  during  the 
period  of  breathing  the  pupils  were  dilated,  while  they  were  con- 
tracted in  the  pause.  The  pulse  was  less  frequent  during  the 
former  than  during  the  latter  phase ;  and  sphygmographic  tracings 
taken  during  these  phases  showed  a  difference  in  character,  the 
pulsations  being  larger,  but  less  regular,  during  the  dyspnoea  than 
during  the  apncea.  It  is  of  interest  to  note  that  the  author  found 
the  apncea  could  be  interrupted  by  powerful  stimuli:  the 
aspersion  of  cold  water,  for  example,  caused  a  deep  breath  followed 
by  dyspnoea.  The  peculiar  rhythm  of  the  respiration  remained 
until  the  death  of  the  patient — twenty-five  days  after  its  first 
appearance.  At  the  post-mortem  examination  it  was  found  that 
the  ventricles  of  the  brain  and  subarachnoid  spaces  were  distended 
with  fluid ;  the  pleural  cavities  contained  each  a  litre  of  fluid ;  the 
heart  was  hypertrophied ;  the  aorta  dilated  and  atheromatous ; 
and  the  kidneys  contracted.  There  was,  in  addition,  a  perforating 
ulcer  of  the  duodenum.  Carrer,  in  conclusion,  passes  the  opinions 
of  other  authors  in  review. 

Baas  ^  describes  the  phenomenon  under  the  name  of  "  inter- 
mittent respiration,"  which  he  prefers  to  the  designation  by  which 
it  is  commonly  known.  In  his  contribution  he  records  the  case  of 
a  female  child,  not  quite  eight  weeks  old,  who  suffered  from  diar- 
rhoea and  hydrocephalus;  the  patient,  amongst  other  symptoms, 
such  as  coma  with  left-sided  ptosis,  and  later,  right-sided  mydriasis, 
developed  Cheyne-Stokes  respiration,  which  continued  for  the 
last  five  hours  of  life  until  death  took  place.  The  author  calls 
attention  in  this  case  to  the  early  period  of  life  at  which  the 
symptom  occurred;  shows  that  it  was  caused  by  acute  hydro- 
cephalus ;  that  it  was  associated  with  unconsciousness  ;  that  in 
this,  as  in  some  other  observations,  the  increase  and  decrease  of 
the  respiratory  energy  was  less  characteristic  than  the  regular 
intervals  of  both  phases  of  the  breathing ;  and  points  to  the  prob- 
ability that  the  condition  was  caused  by  one-sided  pressure  on 
the  respiratory  centre,  as  shown  by  the  ptosis  and  dilatation  of  the 
left  pupil  in  the  early  stage. 

Broadbent  ^  describes  the  occurrence  of  Cheyne-Stokes  breath- 
ing in  a  case  of  apoplexy  with  right-sided  hemiplegia.  There  was 
no  alteration  in  the  state  of  the  pulse  or  heart  during  the  varying 
phases  of  the  symptom,  but  movements  of  the  left  leg  were 
observed  towards  the  end  of  the  pause.  He  states  that  he  has 
often  watched  it  in  ursemic  coma,  and  on  some  occasions  in  sinking 

^  Zur  Percussion,  Auscultation  tmd  Phonometrie,  S.  264,  Stuttgart,  1877. 
This  is  a  reprint  from  a  paper  wliich  appeared  at  an  earlier  period — Deutsche! 
Archivfiir  fclinische  Medicin,  xiv.  Band.,  S.  609,  1874. 

2  The  Lancet,  vol.  i.  for  1877,  p,  307. 


806  DR  G.   A.    GIBSON   ON   THE  [MARCH 

from  exhaustion,  as  well  as  something  very  like  it  once  in  the  case 
of  an  elderly  gentleman  in  his  usual  health.  He  thinks  that  the 
effect  of  the  phenomenon  on  the  pulse  varies,  and  remarks,  "  All 
the  theories  on  the  subject  are  unsatisfactory,  and  I  have  none  of 
my  own  to  offer." 

Wharry^  places  on  record  four  cases  in  which  the  symptom 
occurred.  These  were  mitral  disease  with  aortic  dilatation,  aortic 
and  mitral  disease,  nephritis,  and  typhoid  fever  with  pneumonia. 

Andrew  2  describes  the  phenomenon  as  occurring  in  a  case  of 
typhoid  fever,  which  ended  in  recovery. 

Treves^  mentions  the  development  of  Cheyne-Stokes  respiration 
after  haemorrhage  followed  by  operation,  and  notes  that  drawing 
the  tongue  forward  diminished  the  pauses.  On  section  the  heart 
was  found  to  be  healthy. 

Frost  gives  some  notes  of  a  case  of  apoplexy  *  in  which  the 
symptom  appeared,  and  where  no  variation  could  be  perceived  in 
the  pulse  during  the  different  phases  of  the  breathing. 

One  of  the  most  valuable  contributions  to  the  subject  is  a  study 
of  respiratory  pauses  by  Fran^ois-Franck.^  Having  observed  that 
the  respiration  which  followed  tracheotomy  had  a  great  resemblance 
to  that  with  which  we  are  concerned,  and  being  inclined  to  explain 
this  as  the  result  of  a  free  supply  of  oxygen,  he  investigated  the 
conditions  which  influenced  the  phenomenon.  He  states  that 
with  a  larger  supply  of  oxygen  the  pause  arrives  sooner  and  lasts 
longer,  while  with  a  smaller  supply  the  pause  is  later  and  shorter, 
and  that  the  pause  (or  apnoea,  in  the  sense  of  Filehne)  can  be 
stopped  by  compression  of  the  carotids,  which  hinders  the  carriage 
of  oxygen  to  the  brain,  just  as  in  calm  breathing  compression  of 
these  vessels  induces  forced  respiration.  He  attributes  the  pause 
following  the  suspension  of  artificial  respiration  in  animals  to  ex- 
cessive oxygenation.  Mentioning  the  pause  in  respiration  which 
is  observed  after  the  cessation  of  cardiac jinhibition  caused  by 
stimulation  of  the  peripheral  portion  of  the  vagus,  he  explains  it  as 
being  due  to  excessive  oxygenation  of  the  blood  lying  in  the  lungs 
during  the  cardiac  inactivity,  which  is  thereafter  supplied,  on  the 
recommencement  of  cardiac  action,  to  the  centres,  as  observed  by 
Mayer.  He  describes  experiments  in  which,  after  stimulation  of 
the  central  portion  of  the  vagus,  there  is  complete  arrest  of  respira- 
tion without  any  change  in  cardiac  action.  This  pause,  on  the 
cessation  of  the  stimulation,  is  succeeded  by  large  and  frequent 
respirations,  which  in  turn  are  followed  by  a  complete  pause  due 
to  excessive  oxygenation  of  the  blood.  He  further  calls  attention 
to  the  pause  which  follows  forced  voluntary  respirations  in  man — 

1  The  Lancet,  vol.  i.  for  1877,  p.  368. 

2  Ibid.,  p.  385.  s  75^^.^  p,  481. 
4  Ibid.,  vol.  ii.  for  1877,  p.  238. 

*  Journal  de  Panatomie  et  de  la  physiologie  normales  et  pathologiques  de 
rhomme  et  de$  animaux,  1877,  p.  545, 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  807 

a  pause  accompanied  by  total  absence  of  the  hesoin  de  respirer — as 
being  caused  in  precisely  the  same  manner.  Turning  now  to  the  phe- 
nomena of  Cheyne-Stokes  respiration,  he  mentions  a  case  of  uraemia 
in  which  this  type  of  breathing  occurred.  He  points  out  that  the 
form  of  arrest  in  it  differs  completely  from  that  of  apncea  in  the 
strict  sense  of  that  term,  inasmuch  as  in  Cheyne-Stokes  respiration 
the  pauses  are  gradual  in  their  development  and  cessation,  while  in 
true  apnoea  they  are  abrupt.  In  connexion  with  this  case  he  men- 
tions some  experiments  performed  by  Cuffer,  along  with  himself 
and  Jolyet.  They  injected  ammonium  carbonate  into  the  veins  of 
dogs,  in  accordance  with  one  of  the  theories  of  uraemia,  and  found 
that  these  injections  were  followed  by  arrests  of  respiration. 
These,  however,  were  very  similar  to  the  stoppages  in  apncea,  and 
had  no  resemblance  to  the  pauses  of  Cheyne-Stokes  respiration. 
He  also  describes  another  example  of  Cheyne-Stokes  respiration 
observed  in  a  case  of  mitral  disease  with  cerebral  embolism,  in 
which  also  the  pauses  had  no  resemblance  to  the  arrests  of  respira- 
tion in  apnoea.  He  mentions  that  in  both  the  cases  referred  to 
there  was  an  adynamic  condition,  and  thinks  that  perhaps  the 
suspension  of  the  respiration  may  simply  be  due  to  the  absence  of 
voluntary  participation  in  the  acts  performed. 

Sacchi  ^  describes  a  case  of  aneurism  of  the  ascending  and  trans- 
verse aorta  in  which  Cheyne-Stokes  respiration  made  its  appear- 
ance. The  pause  of  apnoea  could  be  broken  by  opening  the  closed 
eyelids  or  by  speaking  to  the  patient.  Cold  affusion  and  inhala- 
tion of  arayl  nitrite  produced  no  effect,  but  the  inhalation  of  oxygen 
prevented  the  return  of  the  pauses  for  an  hour  and  a  half.  The 
pupils  contracted  during  the  pause  and  dilated  during  the  breath- 
ing, and  when  the  apnoea  was  broken  by  means  of  speaking  to  or 
in  any  way  rousing  the  patient,  they  also  dilated.  The  pulse  was 
very  irregular,  and  sphygmographic  curves  showed  no  constant 
relation  between  the  circulation  and  respiration.  The  sensorium 
was  clouded  during  the  existence  of  the  symptom.  The  post- 
mortem examination  showed  that  there  was  an  aneurismal  dilata- 
tion of  the  ascending  portion  and  arch  of  the  aorta  with  hyper- 
trophy of  the  heart.  Both  vagi  were  found  to  be  compressed  by 
means  of  inflamed  lymphatic  glands  below  the  origin  of  the 
recurrent  laryngeal  nerves,  a  point  of  interest,  inasmuch  as  Traube 
states  that  for  the  occurrence  of  this  phenomenon  both  vagi  must 
be  intact.  The  brain  w^as  anaemic,  and  there  was  some  effusion. 
The  author  will  not  give  his  adhesion  either  to  the  theory  of 
Traube  or  to  that  of  Filehne,  and  he  holds  that  the  result  of  the 
oxygen  inhalations  is  enough  to  disprove  the  view  that  the  apnoea 
is  caused  by  too  little  carbonic  acid  in  the  blood. 

Mosso^  describes  periodic  breathing  of  the  Cheyne-Stokes  type 
as  being  a  natural  feature  of  the  hibernation  of  the  myoxus  during 

^  Rivista  clinica  di  Bologna,  Secondo  Serie,  tomo  vii.  p.  33,  1877. 
2  Archivfiir  Physiologic,  Jahrgang  1878,  S.  441,  1878. 


808  DR   G.    A.    GIBSON   ON   THE  [MARCH 

winter,  when  the  temperature  did  not  exceed  a  certain  limit.  If 
the  thermometer  registers  a  heat  of  more  than  from  lO^-lG"  C, 
however,  the  animal  awakes  from  the  hibernating  condition. 
Mosso  further  states  that  Cheyne-Stokes  breathing  is  to  be  seen 
in  the  sleep  of  healthy  men,  and  this  paper  contains  several 
tracings  of  the  respiratory  movements  taken  in  such  conditions, 

Ottilie^  takes  the  opportunity,  in  describing  a  case  of  senile 
degeneration  of  the  brain,  in  which  this  symptom  occurred,  of 
discussing  the  phenomena  and  causation  of  Cheyne-Stokes  respira- 
tion. He  holds  that  however  varying  the  cases  may  be  in  which  it 
appears,  one  condition  is  constant,  an  insufficient  supply  of  arterial 
blood  to  the  medulla. 

He  further  calls  attention  to  the  fact,  that  if  the  pulmonary 
portions  of  the  vagus  are  rendered  incapable  of  performing  their 
functions,  the  sensory  nerves  from  the  rest  of  the  body  can  induce 
inspiration  when  the  blood  contains  the  amount  of  carbonic  acid 
gas  which,  under  normal  circumstances,  is  only  found  in  the  blood 
of  the  pulmonary  artery,  and  that  this  gives  rise  to  long  pauses. 

Filatow^  describes  two  cases  of  Cheyne-Stokes  respiration  from 
which  recovery  took  place.  One  of  these  was  a  child,  aged  three 
months,  who  suffered  from  dyspepsia  and  inanition ;  the  other  was 
also  a  child,  ten  months  old,  labouring  under  whooping-cough 
accompanied  by  wasting. 

The  observations  of  Cuffer  ^  throw  some  light  on  certain 
aspects  of  the  subject.  These  have  already  been  referred  to 
in  mentioning  the  work  of  Fran9ois-rranck.  After  stating  that 
the  authors  who  have  written  on  the  subject  of  ursemia  make  no 
mention  of  the  state  of  the  blood  corpuscles,  or  of  the  affinity  for 
oxygen  shown  by  the  blood  in  cases  of  Bright's  disease,  he 
describes  a  series  of  experiments  performed  to  discover  what 
changes  are  undergone  by  the  blood  in  that  disease,  and  what  role 
is  played  by  such  changes.  He  shows  that  injections  of  urea  have 
no  effect  on  the  number  of  the  blood  corpuscles  nor  on  the  capacity 
of  the  blood  for  the  absorption  of  oxygen,  while  injections  of 
ammonium  carbonate  and  of  kreatin  reduce  the  former  and 
diminish  the  latter.  Along  with  these  effects  the  injection  of 
these  two  substances  causes  the  appearance  of  a  respiratory 
rhythm  similar  to  that  of  Cheyne-Stokes  breathing.  When  the 
actions  of  these  substances  upon  the  blood  are  tested  in  vitro  it  is 
found  that  urea  has  no  effect,  but  that  carbonate  of  ammonium  and 
kreatin  destroy  the  blood  corpuscles.  In  Bright's  disease  the 
same  effects  are  produced — lessened  number  of  corpuscles  and 
diminished  quantity  of  oxygen.     Cuffer  thinks  it  logical  to  con- 

1  Transactions  of  the  Wisconsin  State  Medical  Society,  vol.  xii.  p.  66,  1878. 

2  Centralzeitung  fiir  Kinderkrankheiten,  Band  ii.  S.  35,  1878. 

3  Recherches  cliniques  et  expe'rimentales  sur  les  alterations  die  sang  dans 
Vur^mie  et  sur  la  pathog(fnie  des  accidents  ur^miques — De  la  respiration  de 
Cheyne-Stokes  dans  I'ur^mie.     Paris,  Librairie  J.  B.  Bailli^re  et  Fils,  1878. 


1889.]  PHENOMENA  IxN    CHEYNE-STOKES   IlESPIEATION.  809 

elude  that  in  diseases  accompanied  by  a  diminution  of  urea  there 
is  generally  a  lessened  number  of  blood  corpuscles ;  that  the 
retention  of  urea,  its  possible  transformation  into  ammonium 
carbonate,  along  with  the  retention  of  other  waste  substances  such 
as  kreatin  and  kreatinin,  form  the  point  of  departure  in  that 
alteration  of  the  blood ;  and  he  regards  these  substances  as  causing 
the  effects  known  under  the  term  uraemia  by  their  action  on  the 
blood.  In  Bright's  disease  the  corpuscles  are  fewer  as  well  as 
more  resistent;  they  do  not  undergo  changes  under  the  influence 
of  reagents — they  are,  in  short,  paralyzed,  and  their  capacity  for 
absorbing  oxygen  is  extremely  diminished.  Turning  to  dyspnoea, 
the  author  shows  that  the  reason  of  the  frequent  occurrence  of 
this  symptom  in  Bright's  disease  is  the  reduced  number  of 
coi"puscles,  and  that  the  acceleration  of  the  respiratory  movements 
is  in  direct  ratio  to  the  diminution  of  the  number  of  the  corpuscles, 
in  connexion  with  which  he  mentions  that  in  leukaemia,  chlorosis, 
and  anaemia  the  same  symptom  depends  on  a  similar  cause.  Car- 
bonate of  ammonium  is  much  more  active  in  the  destruction  of  the 
blood  corpuscles  than  kreatin,  and  it  is  worthy  of  note  that  the 
effects  upon  the  respiration  are  much  more  profound  after  injec- 
tions of  the  former  than  is  the  case  with  injections  of  the  latter 
substance.  In  cases  of  Bright's  disease  the  author  notes  a  spasm 
of  the  arterial  system,  which  he  holds  to  be  a  powerful  factor  in 
determining  the  accession  of  the  exacerbations  of  the  respiratory 
disturbance.  Entering  next  upon  the  consideration  of  Cheyne- 
Stokes  respiration  as  seen  in  uraemia,  he  deals,  firstly,  with  this  as 
a  clinical  symptom,  and,  secondly,  with  the  experimental  produc- 
tion of  similar  phenomena  by  means  of  injections  of  ammonium 
carbonate  and  kreatin.  He  states  that  cases  of  Cheyne-Stokes 
breathing  fall  into  two  classes,  in  one  of  which  there  is  marked 
dyspnoea,  and  in  the  other  little  more  than  a  cessation  of  respira- 
tion. These  two  classes  he  holds  to  correspond  to  the  effects  pro- 
duced respectively  by  carbonate  of  ammonium  and  by  kreatin. 

He  briefly  narrates  seven  cases  of  renal  disease  in  which  Cheyne- 
Stokes  breathing  was  present,  and  which  may  be  shortly  summar- 
ized as  follows : — Mitral  disease  with  consecutive  disease  of  the 
kidneys,  in  which  no  cerebral  symptoms  were  to  be  seen  ;  mitral 
disease  followed  by  renal  affection ;  lead  poisoning  resulting  in 
interstitial  nephritis  with  cardiac  hypertrophy,  where  dilatation 
of  the  pupils  and  muscular  agitation  accompanied  the  dyspnoea ; 
chronic  renal  disease  and  cardiac  hypertrophy ;  interstitial  neph- 
ritis, in  which  the  respiratory  pauses  were  not  complete,  but  were 
represented  by  periods  of  shallow  breathing  ;  chronic  disease  of 
the  kidneys ;  mitral  and  renal  disease ;  gout  and  chronic  renal 
disease,  in  which  Cheyne-Stokes  breathing  seemed  to  have  per- 
sisted for  years;  and  chronic  inflamniation  of  the  kidneys,  in  which 
case  the  vascular  spasm  previously  referred  to  was  well  marked. 

Turning  to  the  experimental  aspect  of  the  subject,  he  describes 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    IX.  5  K 


810  DK   G.   A.   GIBSON   ON   THE  [MARCH 

his  work  in  Marey's  laboratory,  where  he  had  the  assistance  of 
rran9ois-rranck.  The  first  series  of  experiments  was  performed 
by  injecting  ammonium  carbonate  and  kreatin  into  a  vein,  and  the 
results  may  be  briefly  summed  up.  After  injections  of  the  former 
drug,  the  respirations  assumed  the  character  of  Cheyne-Stokes 
breathing,  with  violent  dyspnoea  and  muscular  agitation,  as  well  as 
dilatation  of  the  pupils  during  apncea.  Injections  of  kreatin,  on 
the  other  hand,  simply  produced  Cheyne-Stokes  respiration  of  a 
tranquil  description.  The  employment  of  urea  in  similar  experi- 
ments caused  no  respiratory  symptoms. 

The  second  series  of  experiments  was  intended  to  elucidate  the 
cause  of  apnoea.  After  performing  tracheotomy  on  animals,  which 
manifested  symptoms  of  agitation  during  the  experiment,  apnoea 
appeared ;  and  the  author  refers  in  this  connexion  to  the  same 
symptom  as  it  occurs  after  opening  the  trachea  in  children. 
Apnoea  was  induced  by  keeping  up  artificial  respiration  in  animals 
after  tracheotomy ;  and  Cuffer,  by  means  of  several  ingenious 
experiments  which  cannot  be  described  here,  proved  that  this  con- 
dition was  due  to  superoxygenation  of  the  blood. 

He,  therefore,  regards  the  stage  of  apnoea  in  the  type  of  respira- 
tion which  we  are  considering  as  arising  from  excessive  oxygena- 
tion of  the  blood,  caused  by  dyspnoea  ;  the  recommencement  of  the 
breathing  and  subsequent  dyspncea  as  caused  by  the  want  of  oxy- 
genation due  to  the  arrest  of  respiration  ;  the  superoxygenation  of 
the  blood  and  accompanying  muscular  fatigue  determining  in  turn 
a  new  period  of  apnoea.  He  regards  the  phases  as  caused  by  the 
action  of  the  blood  on  the  medulla  as  well  as  by  the  influence  of 
a  reflex  action  having  its  point  of  departure  in  the  lung,  the  lung 
being  the  special  regulator  of  the  quantity  of  oxygen  needed,  and 
having  its  essential  stimulus  in  the  condition  of  the  blood  which  it 
contains.  The  author,  in  concluding  this  most  admirable  investi- 
gation, finally  directs  attention  once  more  to  the  arterial  spasm  at 
the  beginning  of  the  respiratory  period,  already  mentioned  as  char- 
acteristic of  uraemia,  and  points  out  how  it  influences  the  condition 
of  the  breathing. 

Further  observations  having  been  made  by  Biot,  subsequent  to 
the  publication  of  his  paper  already  reviewed,  he  embodied  them 
in  a  work^  of  much  value.  After  quoting  the  clinical  descriptions 
given  by  Cheyne  and  Stokes,  he  lays  stress  on  the  differences  exist- 
ing between  such  breathing  as  may  be  frequently  seen  in  meningitis 
and  that  known  as  Cheyne-Stokes  respiration,  to  emphasize  which 
he  quotes  from,  or  refers  to,  the  writings  of  many  authors  who  have 
described  the  former.  He  analyzes  the  cases  narrated  by  Bernheim, 
and  asserts  that  the  type  of  respiration  in  some  of  these  was  not 
that  of  Cheyne-Stokes  breathing,  which  he  would  like  to  keep  quite 
apart  from  all  other  varieties  of  respiratory  rhythm.      Passing 

^  Etude  clinique  et  experimentale  sur  la  respiration  de  Cheyne-Stokes.  Paris, 
Librairie  J.  B.  Bailliere  et  Fils,  1878. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   EESPIEATION.  811 

from  this  subject  he  describes  several  cases,  which  may  be  briefly 
referred  to. 

1.  Man,  aged  74,  with  atheroma,  aortic  dilatation,  cardiac  hyper- 
trophy and  degeneration,  with  pleurisy.  2.  Man,  aged  57,  with 
atheroma  and  aortic  and  mitral  disease.  Pulse  less  frequent  in 
dyspnoea;  pupil  dilated  during  that  phase.  3.  (Eeported  by 
Lupine.)  Man,  aged  47,  with  saturnine  renal  disease,  cardiac 
hypertrophy,  and  hemiplegia.  Pupils  contracted  during  apnoea. 
4.  (Eeported  by  Clement.)  Man,  aged  70,  with  mitral  disease  and 
cardiac  hypertrophy.  Pupils  contracted  in  pause.  5.  Man,  aged 
74,  with  cardiac  hypertrophy  and  fatty  degeneration.  Pupils 
contracted  during  apnoea,  and  muscular  spasms  in  that  phase. 
6.  (Eeported  by  Frost,  and  already  mentioned.^)  Man,  aged  63, 
suffering  from  apoplexy.  7.  (Eeported  by  Eocher.)  Man,  aged  46, 
with  aortic  stenosis  and  incompetence  as  well  as  hemiplegia. 
Pupils  small  during  apnoea,  but  pulse  less  frequent  instead  of 
more  so,  as  in  most  cases.  8.  (Eeported  by  Clement.)  Man,  aged 
60,  with  cardiac  failure,  pulmonary  apoplexy,  anasarca,  and  hydro- 
thorax.  Pupils  contracted  during  apnoea.  9.  Man,  aged  77,  with 
mitral  disease  and  cardiac  hypertrophy.     No  pupillary  changes. 

The  author  proceeds  afterwards  to  analyze  the  symptoms  presented 
by  these  cases.  Taking  up  the  apnoea,  he  speaks  of  its  duration 
and  frequency,  and,  as  regards  its  causes,  shows  that  it  may  be 
produced  physiologically  by  superoxygenation,  and  pathologically 
by  want  of  reaction  of  nerve  centres.  Turning  to  the  dyspnoea,  he 
speaks  of  its  duration  and  frequency ;  and  attempting  to  account 
for  its  causation,  he  describes  how  he  repeated  Pilehne's  experi- 
ments on  the  blood  supply  of  the  brain  without  attaining  similar 
results,  which  causes  him  to  conclude  that  the  theory  of  that 
observer  cannot  be  supported,  and  that  the  views  of  Traube  are 
correct.  Taking  up  the  state  of  the  pulse,  he  finds  the  tension  less 
and  the  rate  greater  during  apnoea.  With  regard  to  the  condition 
of  the  eyes,  he  usually  observes  contraction  of  the  pupils  and  con- 
jugate deviation  of  the  globes  during  apnoea.  As  to  the  intellect, 
it  is  usually  clouded  during  apnoea.  Muscular  spasms  are  often 
seen  at  the  end  of  apnoea,  due  to  vagus  irritation.  As  a  means  of 
diagnosis,  he  holds  the  symptom  to  be  a  sign  of  a  double  affection 
— cerebral  and  cardiac.  As  regards  prognosis,  he  considers  it  to 
be  of  very  grave  if  not  fatal  significance.  With  reference  to 
medicines,  he  points  out  the  uselessness  of  all  remedies  tried,  and 
lays  stress  on  the  hurtful  influence  of  many  drugs,  such  as 
hypnotics,  narcotics,  and  substances  reducing  reflex  action.  In 
this  connexion  he  narrates  another  case.  10.  Woman,  aged  53, 
with  bronchitis  and  emphysema,  along  with  tricuspid  dilatation. 
Cheyne-Stokes  breathing  appeared,  and  after  being  present  for 
some  time  disappeared.  To  relieve  dyspnoea  she  had  7  mg.  of 
hydrochlorate  of  morphine,  which  caused  the  reappearance  of  the 
1  Vide  a7itea,  p.  806. 


812  DR   G.   A.   GIBSON   ON   THE  [MARCH 

Cheyne-Stokes  breathing,  followed  by  death.  He  shows,  finally, 
by  experiment  that  drugs  which  induce  or  increase  this  type  of 
respiration  do  so  by  lessening  the  amplitude  and  frequency  of  the 
respiratory  movements,  and  by  developing  a  pause  at  the  end  of 
each  expiration. 

Filehne  promptly  replied^  to  the  strictures  of  Biot,  and  pointed 
out  that  the  latter  had  not  repeated  his  experiments,  which  were  per- 
formed by  stopping  the  current  through  the  vertebrals  as  well  as  the 
carotids,  while  Biot  had  only  compressed  the  carotids,  and  therefore 
left  the  blood  supply  to  the  medulla  almost  untouched.  He  further 
observes  that  the  clinical  arguments  advanced  by  Biot  are  not  more 
convincing,  for  the  fact  that  the  frequency  of  the  pulse  is  greater 
during  the  pause  than  during  the  period  is  not  against  the  theory 
of  the  author.  The  nuclei  of  the  pneumogastric  nerves  may  be 
excited  at  the  end  of  the  pause  at  the  same  time  as  the  vaso-motor 
centre ;  or,  later  than  this,  at  the  same  time  as  the  respiratory 
centre,  so  that  the  lessened  frequency  of  the  pulse  may  be  found 
during  the  end  of  the  pause  or  beginning  of  the  ascending  respira- 
tions. Filehne  refers  Biot  to  his  own  tracings,  which  he  holds  to 
be  proof  of  this.  He  further  expresses  his  opinion  that  the  pheno- 
mena of  the  pupils  may  be  explained  in  a  similar  way.  He  ends 
his  paper  by  remarking  that  he  is  not  called  upon  again  to  refute 
the  theory  of  Traube  which  Biot  wishes  to  resuscitate,  and  adds 
that  in  1875  Traube  addressed  an  oral  communication  to  him,  in 
which,  recognising  how  well  founded  were  his  objections  to  that 
theory,  he  accepted  his  views. 

Biot  at  once  answered^  the  criticisms  of  Filehne  by  the  pub- 
lication of  an  additional  note  on  the  subject.  He  regrets  that,  from 
an  error  in  the  medium  from  which  he  obtained  his  knowledge  of 
Filehne's  observations,  he  had  been  led  to  make  a  mistake  in  his 
control  experiments,  and  accepts  Filehne's  assertion  that  the  pheno- 
mena of  Cheyne-Stokes  may  be  produced  by  alternately  allowing 
and  preventing  the  afflux  of  blood  to  the  brain.  He  again  states 
the  distinction  between  Cheyne-Stokes  respiration  and  other,  more 
or  less  irregular,  modifications  of  respiration.  He  further  reiterates 
his  statement  that  the  arterial  tension  is  higher  during  the  period 
of  apnoea  than  during  that  of  hyperpnoea,  basing  this  upon  tracings 
and  the  application  of  Marey's  law.  He  brings  forward  an  interest- 
ing fact,  that  when  breathing  is  suspended  the  effect  on  the  pulse- 
rate  depends  on  the  phase  of  respiration  during  which  the  stoppage 
takes  place.  When  the  breathing  is  stopped  during  the  phase  of 
inspiration,  there  is  usually  slowing  of  the  heart's  action ;  when, 
on  the  contrary,  it  ceases  during  expiration,  there  is  always 
acceleration.  He  refers  to  his  previous  work,  in  which  he  states 
that  the  apnoea  in  Cheyne-Stokes  respiration  begins  in  the  phase 
of  expiration;   and  again   mentions   that  during  the  pause  the 

*  Revue  mensuelle  de  m/decine  et  de  chirurgie,  deuxieme  annee,  p.  668,  1878. 
2  Ibid.,  p.  935,  1878. 


1889.]  PHENOMENA   IN    CHEYNE-STOKES   RESPIRATION.  813 

arterial  tension  falls,  while  the  rate  of  pulsation  rises.     On  the 
other  hand,  with  the  period  of  breathing  the  reverse  occurs. 

He  further  criticises  the  work  of  Cuffer,  in  which  he  regrets  the 
absence  of  tracings,  and  expresses  his  opinion  that  Cuffer  attributes 
the  dyspnoea  of  uraemia  to  a  cerebral  anaemia  caused  by  a  vascular 
spasm — a  theory  which  he  regards  as  cousin  to  that  of  Filehne. 

He  concludes  by  maintaining  his  conclusions,  that  Cheyne- 
Stokes  respiration  has  a  double  origin — cerebral  and  cardiac. 

Mickle^  has  recorded  three  cases  of  insanity  in  which  Cheyne- 
Stokes  respiration  made  its  appearance.  The  diseases  with  which 
the  symptom  was  associated  were  in  these  three  cases  respectively, 
general  atheromatous  change  with  cardiac  hypertrophy  and  chronic 
renal  disease,  pulmonary  phthisis  with  dilated  heart,  and  apoplexy 
with  epilepsy.  The  author  fully  discusses  the  pathological  con- 
ditions accompanied  by  the  type  of  respiration  in  question,  the 
state  of  the  pulse  during  its  phases,  the  duration  of  these  phases, 
the  disappearance  of  the  symptom  in  some  cases  before  death,  and 
the  arrest  of  the  peculiar  breathing  by  means  of  various  stimuli. 

{To  he  continued.) 


VI.— DISSECTION  OF  A  MONSTROSITY :  Being  a  Report  made 
AT  THE  Request  of  the  Glasgow  Southern  Medical  Society  on 
A  Specimen  submitted  by  Dr  Barras  op  Govan.^ 

By  J.  Stuart  Natrnb,  F.F.P.S.  Glas.,  President,  Glasgow  Obstetrical  and 

Gynsecological  Society. 

External  Appeao-ances. — The  specimen  is  about  10  inches  long, 
and  weighs  11  ounces.  It  consists  of  an  undeveloped  head  and 
several  irregularly-formed  appendages.  One  appendage,  hanging 
from  the  posterior  part  of  the  head,  has  the  general  appearance  of 
the  membranes  of  the  brain.  Another  elongated  body  proceeds 
from  the  lower  part  of  the  head,  and  suggests  the  appearance  of  an 
adigital  limb.  On  the  right  side  of  this  body  another  very  short 
fleshy  one  hangs.  A  fourth  soft  appendage  takes  its  origin  from 
below  the  chin,  and  in  this  one  the  umbilical  vessels  are  contained. 
With  the  exception  of  the  posterior  cephalic  and  the  umbilical 
appendages,  the  whole  is  covered  with  an  apparently  true  skin. 

Head. — The  head  part  is  unilateral.  On  the  left  side  there  is  a 
diminutive  ear ;  the  external  parts  are  complete,  but  there  is  no 
meatus  internus.  The  left  eye  is  represented  by  a  complete  com- 
missure, eyelids,  and  conjunctival  membrane,  but  no  globe.  A 
tiny  central  depression  represents  the  situation  of  the  globe.  The 
right  eye  is  represented  by  a  small  depression  in  the  skin,  but 
there  is  no  appearance  of  eyelids.  The  mouth  is  indicated  by  a 
transverse  slit,  with  a  cleft  in  the  upper  division  extending  back- 

1  British  Medical  Journal,  vol.  ii.  for  1878,  p.  308. 

2  The  specimen  was  one  of  triplets.  The  other  two  were  mature  and 
perfectly  formed. 


814  DK   J.    STUART   NAIRNE   ON  [MARCH 

wards.  The  upper  part  of  the  head  posterior  to  the  line  of  the 
ear  is  thinly  covered  with  hair.  There  is  a  small  quantity  of  the 
white  matter  that  is  usually  found  on  new-born  children  here  and 
there  on  the  skin. 

Dissection. — The  skin  is  tough ;  the  cuticle  does  not  peel  readily 
off.  The  cellular  tissue  is  thick  and  coarse,  and  contains  lumps  of 
fat.  The  muscular  tissues  are  ill  defined,  and  the  specimen  has 
lain  too  long  in  fluid  to  afford  an  opportunity  of  dissecting  them 
to  any  purpose.  The  substance  contained  within  the  cavity  of  the 
skull  by  the  membrane  before  mentioned  has  the  consistence  of 
syrup,  and  is  of  a  reddish,  bloody  appearance.  There  are  no  in- 
dications of  brain  substance  proper.  There  is  no  spinal  medullary 
canal.  The  mouth  opens  into  the  abdominal  cavity.  There  is  a 
cartilaginous  ring,  giving  the  idea  of  a  trachea,  but  it  does  not  lead 
into  lung  tissue,  nor  is  there  any  appearance  of  pulmonary  organs. 
There  is  no  appearance  of  an  organ  that  might  be  taken  for  a 
heart.  The  vessels  of  the  umbilical  cord  are  lost  in  the  abdominal 
walls.  On  maceration,  the  bones  are  found  covered  with 
periosteum,  and  ossification  is  very  well  advanced.  All  the  bones 
in  the  specimen  are  more  or  less  deformed,  but  they  readily 
suggest  the  bones  they  represent.  Almost  every  bone  in  the  body 
may  be  regarded  as  being  represented  in  some  manner.  The  liga- 
mentous tissues  are  firm. 

Plate  I.  Head. — 1.  Lower  maxilla. — Is  more  after  the  normal 
type  towards  the  left  side.  The  more  it  comes  round  to  the  right 
side  the  further  it  gets  from  the  normal  type.  The  alveolar  plates 
are  widely  separated,  and  show  one  distinct  small  socket  at  the  right 
end  and  a  larger  cavity  running  from  that  point  up  to  the  root  of 
the  condyle.  The  condyle  and  the  coronoid  process  are  both  very 
well  marked. 

2.  Upper  maxilla. — Is  not  much  ossified.  The  alveolar  arch  is 
altogether  cartilaginous.  The  palate  is  of  a  soft  cartilaginous 
nature.  This  has  all  been  cut  away.  The  part  remaining  shows 
the  sockets  of  five  teeth.  These  two  parts  are  almost  perfectly 
represented  in  Dr  Gordon's  plates.  (Plate  xii.,  figs.  5,  6,  8,  and 
9,  drawn  by  Mr  Fox.) 

3  and  4.  Malar  and  nasal  bones. 

11.  Corresponding  bone  on  other  side. 

5  and  6.  Bones  that  form  orbital  plate.  There  is  no  eyeball  in 
orbit,  and  no  tapering  of  orbital  bones  from  before  backwards 
towards  entrance  of  optic  nerve  and  vessels  into  orbit. 

10,  7,  17,  16.  Parts  of  bones  of  head. — Ossified  portions  only,  the 
rest  disappearing  in  maceration. 

14.  Temporal  bone.  —  Shows  only  a  depression  for  internal 
meatus. 

15.  Bones  from  temporal  bone. — In  all  probability  representing 
semicircular  canals. 

8.  Occipital  bone,  to  the  smooth  edge  of  which  the  membrane 


1889.]  DISSECTION   OF  A   MONSTROSITY.  8l5 

was  attached.  At  one  side  a  cavity,  possibly  representing  cavity 
for  medulla  spinalis. 

13.  Small  pieces  of  bone  in  connexion  with  11  and  3. 

Plate  II.  Body. — 1,  1,  etc.  The  bones  about  the  neck  immedi- 
ately attached  to  the  head;  fragments, probably,  of  spinous  processes 
and  bodies  of  vertebrae. 

2.  Solid  bone,  probably  body  of  vertebra. 

3.  Vertebra  prominens. 

4.  The  spinal  column,  part,  half  turned  round  so  as  to  show 
attachment  of  ribs  to  left  side. 

5.  Deformed  and  misplaced  ilium. 

6.  Pelvic  bone,  with  articulation — not  ossified — for  femur. 

7.  Femur. 

8.  Epiphysis  of  tibia. 

9.  Tibia. —  Deformed;  terminating  in  a  point  simulating 
phalangeal  termination. 

12.  Seven  ribs  attached  and  split  at  their  spinal  ends;  three 
lower  ribs,  not  attached  and  not  split. 

13.  Sternum. 

11.  Clavicle,  well  formed. 

10.  Scapula. 

Notes. — Monsters  are  a  sport  of  Nature.  Although  they  may  be 
classified  as  acephalous,  anencephalous,  etc.,  it  is  merely  accidental 
circumstances  that  put  any  specimen  into  a  particular  class.  There 
is  no  rule,  that  is  to  say,  for  the  production  of  malformations  ;  at 
any  rate,  there  is  no  rule  at  present  known. 

It  does  not  even  follow,  what  would  seem  to  be  a  most  reason- 
able supposition,  that  the  absence  of  any  one  part  of  the  economy 
necessarily  entails  absence  of  any  other  part,  although  that  other 
part  may  be  regarded  as  depending  on  the  former.  For  instance, 
absence  of  the  brain  does  not  necessarily  include  absence  of  the 
usual  nerve  system,  or  of  organs  at  least  suggesting  it.  In  the 
present  instance  there  is  no  evidence  of  a  heart,  but  the  bones  are 
abundantly  perforated  for  the  passage  of  vessels  of  some  kind. 
And  in  all  probability,  up  till  the  moment  of  the  birth  of  this 
monstrosity,  maternal  blood  circulated  through  it  as  it  did  through 
the  other  foeti. 

Every  part  of  the  development  of  this  specimen  differs  in  some 
respects  from  the  normal.  For  example,  these  thickened  plates  of 
parietal  bone  differ  very  materially  from  the  thin  lamellae  that 
constitute  the  same  bones  in  a  mature  natural  foetus.  Look  also 
at  the  thickened  lump  of  bone  constituting  the  supra-orbital  ridge 
and  superior  orbital  plate  of  the  frontal  bone.  Behind  and  to  the 
outside  of  this  orbital  fissure  there  is  a  depression  leading  down 
towards  the  left  angle  of  the  mouth.  This  hollow  was  filled  with 
strong  muscular  tissue,  and  there  can  be  no  doubt  that  it  repre- 
sented the  masseter  muscle  falsely  placed,  terminating  on  the  upper 
maxilla  instead  of  passing  down  to  the  lower  jaw. 


816  DISSECTION   OF   A   MONSTROSITY.  [mAKCH 

The  whole  specimen  seemed  at  first  sight  and  from  outward 
inspection  to  be  a  head  with  an  arm.  We  now  see  that  the  head 
has  rolled  up  in  it  a  curved  spine,  rotated  back  half  on  itself,  with 
true  ribs,  a  scapula,  and  clavicle  all  on  the  left  side.  The  arm  is 
not  an  arm,  but  a  leg  attached  by  a  small  head  to  the  left  pelvic 
bone.  On  the  right  side  of  the  spine  we  find  a  malformed  flat 
bone,  in  its  general  outline  indicating  the  right  ilium.  Its  attach- 
ment to  the  spine  is  by  soft  cartilaginous  tissue.  There  is  not  the 
slightest  appearance,  depression  or  elevation,  indicating  genital 
organs.  The  slight  fleshy  prolongation  at  the  right  side  of  the 
lower  limb,  suggesting  a  right  limb,  contains  no  bone.  It  is  com- 
posed of  cutaneous  and  subcutaneous  cellular  tissues. 

The  specimen,  then,  has  its  left  side  very  well  represented,  and 
might  therefore  be  called  "sinistral."  The  right  side  is  simply 
indicated  in  the  head,  having  the  situation  of  organs  indicated 
merely  by  points  or  depressions.  In  the  body  the  right  side  is 
absent.  There  are  no  digits.  It  might  then,  to  give  it  a  name, 
very  appropriately  be  designated  a  "  hemicephalic  sinistral  adigital 
monster." 


VII.—A  CONTRIBUTION  TO  THE  PATHOLOGY,  SYMPTOMS, 
AND  TREATMENT  OF  ADHERENT  PLACENTA. 

By  D.  Berry  Hart,  M.D.,  F.R.C.P.E.,  F.R.S.E.,  Lecturer  on  Midwifery 
and  Diseases  of  Women,  Surgeons'  Hall,  Edinburgh ;  Assistant  Obstetric 
Physician,  Royal  Maternity  and  Simpson  Memorial  Hospital,  Edinburgh  ; 
Assistant  Gynaecological  Physician,  Royal  Infirmary. 

{Read  before  the  Edinburgh  Obstetrical  Society,  \2th  December  1888.) 

Few  complications  of  the  third  stage  are  more  disliked  by  the 
obstetrician  than  adherent  placenta.  While  not  now  the  bugbear 
it  was  in  former  times,  yet  the  risks  of  haemorrhage  and  septic 
mischief  make  it  still  formidable,  although,  fortunately,  the  latter 
complication  is  rare  and  thoroughly  preventible.  We  are  not  yet 
in  a  position  to  explain  the  pathology  of  this  complication.  Indeed, 
to  do  so  in  any  instance  would  require  such  an  extended  know- 
ledge of  the  case  before  conception  and  after  labour  as  must 
necessarily  be  rare.  I  believe  that  obstetricians  are  to  blame  in 
not  more  thoroughly  examining  the  shed  placentse  in  adherent 
cases,  although  it  may  be  urged  that  the  mischief  is  probably  in 
the  spongy  layer  and  next  the  external  wall.  Granting  even  this, 
we  do  not  as  yet  know  the  microscopic  anatomy  of  such  cases  as 
we  ought. 

My  attention  has  been  directed  to  this  subject  from  my  very  good 
fortune  in  obtaining  a  remarkable  specimen  of  an  inverted  third 
stage  uterus  with  the  placenta  adherent.  As  the  microscopical 
anatomy  of  the  specimen  is  interesting,  and  seems  to  me  to 
partially  explain  such  a  complication,  I  have  brought  it  before 


1889.]  THE   PATHOLOGY,  ETC.,   OF   ADHERENT  PLACENTA.  817 

your  notice  to-night  along  with  some  remarks  on  its  clinical 
aspects. 

In  examining  this  specimen,  I  did  so  by  making  microscopical 
sections  of  the  entire  thickness  of  the  uterine  wall  and  placenta 
by  the  celloidin  process,  so  as  to  ascertain  the  difference  of  structure 
and  arrangement  in  the  serotinal  layer  as  compared  with  a  normal 
third  stage  uterus  also  with  the  placenta  attached.^ 

In  the  normal  specimen  we  can  recognise  the  following  parts 
between  villi  and  uterine  wall : — 

1.  Where  the  serotina  and  villi  meet  we  have  a  band  of  dense 
tissue,  which  stains  more  deeply,  and  is  apparently  formed  by  a 
blending  of  villi  and  serotinal  tissue.  Owing  to  its  density  its 
exact  structure  is  difficult  to  make  out  accurately,  but  it  is  prob- 
ably connective  tissue,  and  processes  from  it  pass  up  between 
the  villi  forming  the  partitions  between  the  lobes.  Occasionally 
one  sees  in  it  some  of  the  cells  of  the  large-celled  layer. 

2.  The  large-celled  layer,  sharply  differentiated  from  the  former, 
and  made  up  of  large  endothelial-like  cells,  with  nucleus  and 
nucleolus.  Scattered  through  this  layer  are  many  nuclei  which 
stain  deeply  with  logwood. 

3.  The  spongy  layer. — This  is  a  broad,  well-defined  layer,  with 
large  spaces  lined  by  perfect  columnar  epithelium. 

4.  A  much  less  meshy  layer  lying  on  the  uterine  muscle. 
The  contour  of  the  muscle  is  not  flat  but  toothed. 

In  the  sections  of  the  adherent  placenta  the  same  structures 
can  be  made  out,  but  the  mesh-work  or  spongy  layer  is  imich  less 
marked,  the  spaces  are  markedly  smaller,  and  in  none  of  them  can 
epithelium  he  detected.  There  is  no  evidence,  however,  of  chronic 
inflammatory  affection — a  point  on  which  I  had  the  valuable 
advice  of  Dr  Woodhead.  The  cause  of  the  non-separation  here 
depended  apparently  on  the  defective  development  or  pathological 
condition  of  the  mesh-work  or  spongy  layer,  where  the  normal 
plane  of  separation  for  the  placenta  lies.  How  this  has  happened 
I  am  unable  to  explain,  but  the  way  in  which  it  prevents  separa- 
tion is  too  evident  to  require  special  remark. 

Cases  of  adherent  placenta  vary  much  in  their  degree,  and 
range  from  those  where  no  haemorrhage  accompanies  the  third 
stage,  and  where  the  separation  of  the  placenta  is  easily  performed 
by  the  hand,  up  to  those  where  there  is  profuse  haemorrhage, 
sometimes  proving  rapidly  fatal,  as  well  as  those  where  separation 
is  effected  manually  with  the  greatest  difficulty  even  by  the  most 
skilled,  and  where  the  patient  runs  grave  risk  of  septicsemia.  A 
clinical  classification  of  adherent  placenta,  therefore,  seems  to  me  a 
requisite,  and  I  submit  the  following  as  one  based  on  the  gravity  of 
the  case,  and  thus  giving  an  idea  of  the  prognosis. 

1  Drawings  of  the  placenta  in  adherent  and  normal  third  stage  cases  are 
given  in  the  Proceedings  of  the  Royal  Society,  Edinburgh,  for  1888,  and  the 
Laboratory  Reports  of  the  Royal  College  of  Physicians,  Edinburgh,  vol.  i. 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    IX.  5  L 


818  DR  D.  BEERY  HART  ON  THE  [MARCH 

1.  Cases  of  total  adhesion,  unaccompanied  hy  hcemorrhage,  where 
the  separation  of  the  placenta  manually  is  easy,  and  is  accomplished 
in  the  normal  plane  of  separation. 

2.  Cases  of  partial  adhesion  high  up  in  the  uterus  ivhere  the  pla- 
centa is  separated  in  its  lower  part,  often  accompanied  hy  serious 
hcemorrhage.     The  upper  adhesion  is  extensive. 

3.  Cases  of  adhesion  lou>  doum,  the  placenta  being  separated  above; 
not  usually  accompanied  with  hcemorrJiage. 

4.  Cases  of  very  perfect  adhesion,  usually  accompanied  with  little 
hcemorrhage,  but  where  separation  is  effected  manually  with  great 
difficulty.  The  placenta  is  usually  separated  where  the  villi  and 
serotina  meet,  and  thus  the  uterus  is  left  with  the  usual  deciduous 
layer  of  the  serotina  still  adherent,  and  often  with  portions  ofthefcetal 
placenta  attached. 

This  classification  is  of  course  a  sharp  one,  and  combinations  of 
the  varieties  often  occur.  The  first  class  is  the  typical  and  easy 
one.  The  patient  has  probably  had  a  previous  endometritis,  has  a 
slow  second  stage,  and  then  a  third  stage  where  the  placenta  is 
not  separated  and  expelled  in  the  usual  time.  I  have  noticed  this 
slow  second  stage  occasionally,  and  usually  set  it  down  to  in- 
effective uterine  pains  owing  to  the  adhesion  preventing  proper 
uterine  retraction.  During  the  third  stage  the  uterus  may  con- 
tract irregularly,  developing  nodules,  as  it  were,  in  its  contour. 
As  the  placenta  is  not  expelled  within  three  quarters  of  an  hour, 
and  is  still  in  the  uterus  and  unseparated,  the  obstetrician  makes 
up  his  mind  to  separate  manually,  a  procedure  easily  accomplished. 
I  need  not  give  the  details  of  this,  but  remark  that  the  patient 
must  be  chloroformed,  the  vagina  douched  with  corrosive  sublimate 
(1  in  3000).  The  dorsal  posture  is  the  best,  and  both  hands  are 
employed,  the  outer  one  to  steady  and  depress  the  uterus  as 
required.  The  separation  of  the  placenta  is  best  effected  from 
below  up,  the  entire  separation  being  finished  before  expulsion  is 
brought  about.  Sometimes  confusion  to  the  inexperienced  operator 
is  caused  by  his  passing  his  hand  within  the  membranes  instead 
of  keeping  outside  them.  That  an  antiseptic  uterine  douche  be 
used  after  full  expulsion,  goes  without  saying. 

The  second  class  of  case  gives  by  far  the  most  serious  complica- 
tion at  the  time.  Blood  pours  from  the  relaxed  uterine  wall 
where  the  lower  part  of  the  placenta  is  separated,  while  the  attach- 
ment above  hinders  uterine  retraction.  The  attendant,  despite  all 
care  to  secure  retraction  by  legitimate  grasping  and  friction  of  the 
uterus,  by  hypodermics  of  ergotine,  and  the  use  of  the  hot  douche, 
fails,  and  unless  the  placenta  is  promptly  separated  manually,  so 
as  to  remove  the  cause  of  inefficient  uterine  action,  the  case  may 
speedily  become  serious.  Cases  of  ordinary  flooding  so  readily,  as 
a  rule,  yield  to  the  usual  means  given  above,  that  manual  removal 
of  the  placenta  is  quite  unnecessary  interference.  I  think,  how- 
ever, that  we  err  in  waiting  in  this  class  of  adherent  placenta 
before  resorting  to  separation  by  the  use  of  the  hand.     No  doubt 


1889.]  PATHOLOGY,   ETC.,   OF   ADHERENT   PLACENTA.  819 

the  mistake  can  be  rendered  harmless  by  antiseptics,  and  further, 
the  advice  given  here  may  be  abused  by  the  inexperienced,  but 
experience  will  correct  the  error  of  undue  meddling.  I  wish, 
therefore,  to  urge  caution  in  this  instance,  viz.,  the  attendant  must 
always,  in  a  flooding  that  looks  threatening,  remember  the  pos- 
sibility of  this  dangerous  upper  adhesion  of  the  placenta  with  the 
lower  part  separated.  The  greater  the  adhesion  above  the  greater 
the  risk. 

The  fourth  class  is  not  accompanied  by  flooding,  but  the  union 
of  uterus  and  placenta  is  so  dense  that  separation  is  a  matter  of 
immense  difficulty.  The  placenta  in  such  cases  is  separated 
where  the  villi  and  serotina  blend,  and  the  separated  placenta  is 
practically  the  foetal  portion  with  amnion  and  chorion.  This  is 
the  case  where  septicaemia  is  to  be  feared.  The  uterus  is  left  lined 
by  a  layer  of  dead  tissue,  affording  a  nidus  for  infection,  and  expos- 
ing the  patient  to  the  gravest  septic  risks.  Such  require  most 
stringent  antisepsis  during  the  puerperium,  and  the  immediate  use 
of  the  intrauterine  douche  if  any  threatening  of  mischief  arise. 

Separation  of  the  placenta  when  adherent  may  occur,  therefore,  in 
the  following  planes :  {a)  Where  villi  and  serotina  blend ;  (h)  in 
normal  trabecular  layer ;  (c)  even  at  a  superficial  distance  below 
muscle,  usually  only  partial. 

In  conclusion,  I  would  urge  a  more  systematic  microscopical 
examination  in  all  cases  of  adherent  placenta,  especially  where 
any  superficial  muscle  is  removed. 


VIIL— ARTIFICIAL  LIMBS. 

Part  II. — Sites  for   Amputation  in  the  Lower  Limb  in  Relation 
TO  Artificial  Substitutes. 

By  Charles  W.  Cathcart,  M.B.,  F.R.C.S.,  Eng.  and  Edin.,  Assistant 
Surgeon,  Royal  Infirmary,  Edinburgh ;  Lecturer  on  Surgery,  Edinburgh 
School  of  Medicine. 

(Read  hefore  the  Medico-Chirurgical  Society  of  Edinburgh,  &th  February  1889.) 

In  a  former  paper  I  endeavoured  to  show  that,  in  spite  of  a 
consensus  of  opinion  by  instrument  makers  to  the  contrary,  in 
amputations  of  the  foot,  and  so  far  as  after  usefulness  was  con- 
cerned, there  was  every  reason  why  surgeons  should  save  as  much 
of  the  natural  parts  as  the  nature  of  the  case  permitted.  More- 
over, from  a  study  of  the  physiology  of  locomotion,  it  seemed  to 
follow  that  the  principle  of  "  the  least  sacrifice  of  parts "  in  the 
lower  limb  ought  to  be  as  applicable  to  modern  surgery  as  it  ever 
had  been  before.  The  justifiability  of  removing — with  the  view 
to  an  artificial  limb — more  of  the  natural  parts  than  would  have 
been  otherwise  necessary  was  not  considered,  because  the  advantage 
to  be  gained  by  so  doing  did  not  seem  to  me  to  have  been 
established. 


820  MR   CHARLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.     [MARCH 

It  remains  still  to  be  considered  how  far  from  practical  as  well 
as  from  tlieoretical  considerations  the  same  conservative  principle 
may  apply  to  the  leg  and  thigh.  Our  first  duty  will,  therefore,  be  to 
inquire  whether  instrument  makers  really  make  the  same  demand 
on  surgeons  for  the  leg  and  thigh  that  they  do  for  the  foot 
One  maker,^  at  least,  who  has  recently  published  his  views  very 
widely,  speaks  with  no  uncertain  sound.  "  If,"  he  says,  "  the  heel 
cannot  be  saved,  save  the  knee-joint  and  its  due  length  of  stump, 
and  amputate  somewhere  in  the  middle  third  of  the  lower  leg 
(tibia) ;  and  if  the  knee  and  its  functions  cannot  thus  be  preserved, 
amputate  as  low  in  the  middle  third  of  the  thigh  (femur)  as 
possible."  As  a  commentary  upon  these  rules,  we  may  quote  other 
passages  from  the  same  author.  Thus,  under  the  head  "Amputations 
through  the  Tibia,"  he  says,  "  It  is  obvious  that  one  must  not 
amputate  too  low,  because  a  certain  amount  of  space  is  required 
for  the  ankle-joint  mechanism  (and  this  space  is  at  least  about 
four  inches  from  the  ankle-joint  or  six  inches  from  the  heel).  It 
is  also  obvious  that  if  the  amputation  is  performed  too  near  the 
knee,  then  the  stump  left  below  the  knee  is  of  little  or  no  service 
in  governing  its  portion  of  the  artificial  leg ;  nay,  further,  a  very 
short  stump  below  the  knee  almost  invariably  contracts  in  a  flexor 
direction,  and  becomes,  therefore,  a  great  inconvenience  rather  than 
the  reverse.  In  an  adult,  for  the  stump  to  be  of  any  service,  at 
the  very  least  four  inches  below  the  knee  should  be  left.  Tlie 
absolute  range  of  election  is  therefore  from  four  below  the  knee  to 
four  above  the  ankle,  but,  practically,  it  is  about  the  middle  third, 
and  the  lower  in  this  the  amputation  is  performed,  the  more  perfect 
will  be  the  government  gained  over  the  artificial  leg.  Consequently 
the  actual  point  of  election  will  be  a  little  lower  than  half  way 
down  the  tibia ;  while  if  it  is  impossible  to  leave  a  stump  up  to 
four  inches  length,  then  it  is  perhaps  better  not  to  amputate 
through  the  tibia  at  all,  but  higher  up  "  (pages  23,  24),  i.e.,  four 
inches  from  the  condyloid  surfaces  of  the  joint. 

There  can  be  no  doubt  as  to  what  is  here  meant.  As  in  the  foot, 
so  in  the  leg  and  up  to  the  lower  third  of  the  thigh,  surgeons 
are  to  give  up  "  least  sacrifice  of  parts,"  in  order  partly  to  give 
room  for  the  mechanism  of  artificial  joints  (above  ankle  and 
knee),  partly  to  facilitate  control  of  artificial  limb  by  stump 
(below  knee),  and  partly  lest  the  stump  should  be  not  only  useless 
but  "a  great  inconvenience"  (below  the  knee).  So  sweeping  a 
demand  is  almost  its  own  condemnation,  but,  as  it  is  made  in  the 
name  of  large  instrument-making  experience,  we  nmst  give  it 
careful  consideration.  There  seem  to  me  to  be  four  points  of 
view  from  which  this  question  may  be  considered : — 

(1.)  From  the  theoretical  or  a  priori,  i.e.,  from  a  study  of  the 
physiology  of  locomotion. 

(2.)  From  that  of  the  author,  by  considering  his  own  arguments 
in  defence  of  his  position. 

*  Artificial  Limbs,  by  Heather  Bigg,  1885. 


1889.] 


Mii   CHARLES    W.    CATHCART   ON    ARTIFICIAL   LIMBS. 


821 


(3.)  From  that  of  other  instrument  makers. 

(4.)  From  that  of  personal  experience. 

1.  Physiological  hiquiry. — This  I  think  I  have  already  stated^ 
with  sufficient  fulness,  when  I  showed  that  in  the  knee,  no  less 
than  in  the  ankle,  there  were  movements  in  the  passive,  but 
specially  in  the  active  phase^  of  the  step,  which,  when  lost,  no 


mechanism  could  replace,  and  that  the  longer  the  stump  of  the 
lower  limb  as  a  whole,  the  more  the  leverage  and  the  greater  the 
propelling  power  of  the  thigh,  even  when  the  stump  below  the 
knee  was  too  short  to  allow  it  to  control  the  artificial  limb. 

2.  The  chief  reason  given  for  urging  surgeons  to  leave  so  much 
as  4  inches  above  the  knee  and  ankle  is  that  without  this  space 
the  rule-joints  instead  of  the  pivot  or  hinge  joints  would  be 
required,  and  that  rule-joints  are  much  inferior  to  the  otliers. 

From  a  calculation  based  on  the  breadth  of  weight-bearing 
surface  Heather  Bigg  alleges  the  inferiority  to  be  as  1  to  43. 
Assuming  this  to  be  theoretically  correct,  and  considering  first  the 
ankle,  it  is  difficult  to  see  how  so  much  as  4  inches  of  space 
above  the  ankle  is  called  for  when  the  ankle  mechanism  for  a 
Syme's  or  a  Pirogoff  s  stump  is  not  only  provided,  but  is  called  "  one 
of  the  most  perfect  in  the  range  of  mechanical  appliances"  (page  45). 

Why  might  the  ankle  movement  provided  for  one  of  these  two 
operations  not  be  supplied  for  an  amputation  higher  up  ?  The 
difference  in  bearing  will  surely  not  explain  it,  because  this  maker 
often  takes  the  bearing  of  a  Syme  or  of  a  Pirogoff  at  the  ischium. 

1  "Artificial  Legs,"  Part  I.,  Edin.  Med.  Journal,  March  1888. 

2  The  slightly  flexed  knee,  as  the  body  passes  over  the  supporting  leg  (see 
Fig.  1),  and  the  combination  of  an  extended  knee  at  one  time  with  a  flexed 
and  at  another  time  with  an  extended  ankle-joint  (see  Fig.  2). 


822  MR   CHARLES   W.   CATHCART   ON  ARTIFICIAL   LIMBS.     [MARCH 

But,  again,  these  rule-joints,  bearing  at  the  knee  nearly  the 
entire  weight  of  the  body,  are  provided  by  this  maker  for  all 
amputations  above  those  at  the  ankle,  since  he  holds  that  for 
every  amputation  above  a  Syme  or  a  Pirogoff  the  bearing  of  "  the 
artificial  limb  should  be  entirely  taken  on  the  very  top  of  the 
thigh,  and  more  particularly  on  the  ischial  tuberosity  or  sitting 
bone."  "  The  artificial  limb  must  reach  to  the  ischium,  or,  in 
other  words,  must  enclose  and  embrace  the  full  entirety  of  what 
part  of  the  natural  limb  is  left  from  the  buttock  downwards,  .  .  . 
and  so  transmit  the  weight  of  the  body  directly  from  the  pelvis  to 
the  ground." 

Whether  this  plan  is  or  is  not  necessary  we  need  not  here 
discuss,  but  since  this  maker  must  use  these  joints  in  a  large 
proportion  of  his  artificial  limbs,  it  seems  strange  that  to  get  rid 
of  the  need  for  them  in  certain  other  cases  he  should  ask 
surgeons  to  remove  8  inches  of  a  patient's  lower  limb  more  than 
would  have  been  otherwise  necessary.  In  addition  to  the  above, 
more  than  one  dealer  in  artificial  limbs  has  told  me  that  he  finds 
very  little  difference  between  the  lasting  powers  of  rule  and  of 
the  other  form  of  joint. 

3.  Other  Makers. — In  the  series  of  questions  which  I  put  to 
instrument  makers  I  specially  framed  five  to  bear  upon  the 
present  discussion  relative  to  the  knee.  (The  distance  thought 
necessary  to  leave  above  the  ankle  I  unfortunately  omitted  to  ask.) 
We  may  divide  the  inquiry,  meanwhile,  into  amputations  below 
and  above  the  knee.  If  we  turn  to  the  answers  to  these 
questions,  we  shall  find  that  the  opinion  of  instrument  makers  is 
much  more  divided  upon  them  than  it  was  upon  the  advisability 
of  sweeping  away  the  whole  foot  if  part  were  destroyed. 

The  two  questions  bearing  on  amputations  through  the  upper 
part  of  the  tibia  were — "  What  length  of  stump  below  the  knee  do 
you  find  it  necessary  to  leave  in  order  that  the  movements  of  the 
artificial  limb  may  be  controlled  by  those  of  the  stump  ? "  and, 
"Does  the  seat  of  election  give  too  short  a  stump  for  this  purpose?" 
To  the  first  of  these  questions,  i.e.,  No.  2  of  the  series,  the  answers 
varied.  IV.^  replied  4  inches  ;  5  inches  was  the  reply  of  III.,  VI., 
VII.,  and  VIII. ;  5  or  6  inches  of  II. ;  the  junction  of  middle  and 
lower  third  of  leg  of  I.  and  V. ;  8  inches  from  patella  of  IX.  XI. 
replied,  "  Never  amputate  lower  than  2  inches  above  ankle-joint, 
and  never  leave  less  than  2|  inches  of  tibia  below  patella." 

Indirectly,  in  replying  to  this  question,  several  gave  answers 
bearing  also  on  the  next  question.  Thus  IV.  says,  "  I  have  fitted 
patients  with  only  3  inches  below  the  knee  and  they  walk  well." 
VII.  says,  "  A  serviceable  limb  can  be  applied  to  any  stump,  but 
unless  5  inches  are  left  below  the  condyles  of  the  knee  we  often 
have  to  insert  springs  or  other  mechanism  to  enable  the  wearer  to 
control  the  movements  of  the  leg."  X.  says,  "  We  can  apply  a  leg 
1  See  list  of  Instrument  and  Limb  Makers  at  end  of  paper. 


1889.]         MB   CHARLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.  823 

to  a  stump  1|  inches  below  the  popliteal  space,  and  use  the  stump 
in  controlling  the  knee  movement  of  the  artificial  leg ;  this,  how- 
ever, is  somewhat  short,  and  cannot  be  expected  to  do  the  work  of 
a  longer  stump." 

To  the  question  with  reference  to  the  seat  of  election,  I.  replied, 
"  Yes,  it  necessitates  a  kneeling  leg ; "  II.  and  III.,  "  Yes ; "  IV. 
implied  "  Yes ; "  while  the  answer  of  V.  was  not  to  the  point. 
XII.  replied,  "  Never  leave  less  than  2|  inches  of  tibia  below 
patella ; "  on  the  other  hand,  VI.  reported  that  he  had  often  suc- 
cessfully fitted  such  cases.  The  answer  of  VII.  has  already  been 
partly  given ;  he  also  here  stated,  "  Yes,  for  effective  control,"  but 
would  recommend  going  from  middle  third  of  leg  to  "  through  the 
knee."  VIII.  said  that  "  the  seat  of  election  is  rather  too  short, 
but  we  have  some  very  good  cases  of  that  kind."  IX.  said,  "  In 
all  cases  it  is  very  desirable  to  save  the  knee-joint,  even  if  the 
stump  is  but  2  inches  long.  In  that  case  an  artificial  limb  can  be 
so  adjusted  that  the  patient  will  walk  very  nicely." 

It  would  have  been  better  had  I  definitely  asked  if  above  the 
knee  would  have  been  preferable  to  less  than  4  inches  below  it ; 
but  the  answers  brought  out  by  the  question  as  I  put  it  seem 
clearly  enough  to  show  that  many  makers  are  prepared  to  deal 
with  any  stump,  however  short,  below  the  knee. 

Since  the  bent  knee  is  so  well  adapted  for  bearing  pressure, 
one  naturally  asks  if  with  a  short  stump,  in  which,  either  from 
stiffness  or  extreme  shortness,  the  knee-joint  cannot  be  utilized, 
an  artificial  limb  with  movable  knee  cannot  be  adopted  in  which 
the  "bearing"  is  taken  on  the  flexed  knee.  This,  I  find,  is 
much  desired  by  many  of  the  makers,  and  is  spoken  of  in  their 
books  descriptive  of  their  limbs  as  quite  an  usual  appliance. 
As  an  example,  X.  refers  thus  to  one  of  his  figures :  "  Fig.  3 
is  a  knee-bearing  leg.  It  is  to  be  applied  where  amputation 
takes  place  below  the  knee,  and  where  the  stump  is  too  short 
or  contracted  at  right  angles  so  the  knee-joint  cannot  be  used 
in  walking."  Other  makers  express  a  similar  opinion.  II.  also 
writes :  "  In  a  case  of  amputation  at  seat  of  election  it  is 
best  to  bend  the  knee  to  a  right  angle,  and  have  the  artificial 
leg  arranged  with  a  socket  in  which  the  stump  would  rest 
front  downwards,  the  leg  having  lateral  knee-joints  ;  the  stump 
would  thus  project  backwards."  Hence  we  may  conclude  that 
even  should  the  stump  be  too  short  or  too  stiff  to  control  the 
artificial  limb,  the  "  knee-bearing  "  and  also  longer  stump  will  be 
preferable  to  a  higher  amputation. 

4.  I  have  myself  seen  stumps  of  "  seat  of  election  "  amputations 
admirably  fitted  with  artificial  limbs  with  movable  knees,  but 
have  not  as  yet  seen  any  with  kneeling  bearing.  When  such  is 
employed  I  would,  on  general  grounds,  consider  that  the  best 
results  would  be  attained  by  insuring  that  the  thigh  and  not  the 
leg-piece  of  the  artificial  limb  took  the  "  bearing."  See  Part  I., 
page  16. 


824  MR   CHARLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.     [MARCH 

Above  the  Knee. — When  no  portion  of  the  tibia  can  be  saved,  the 
surgeon  has  to  choose  between  amputation  through  the  knee-joint, 
through  the  condyles  (Garden  or  Gritti),  or  at  sufficient  distance 
above  the  joint  to  permit  of  a  hinge-joint  knee  mechanism.  What 
are  the  advantages  and  disadvantages  of  each  ?  Considering  this 
question  under  the  same  heads  as  before — 1.  Physiological,  the  need 
for  leverage  is  as  much  seen  here  as  in  any  of  the  places  already 
noticed.  2.  The  contention  for  the  higher  amputation  is  that  suffi- 
cient room  is  not  left  for  an  artificial  knee-joint ;  but  as  rule-joints 
have  already  been  shown  not  to  be  such  a  great  evil,  this  argument 
does  not  count  for  very  much  after  all,  especially  as  I  shall  after- 
wards show  that  the  only  other  possible  mechanism — tendo  Achilles 
— for  which  room  might  be  required,  carries  no  real  advantage  with 
it.  3.  Other  makers.  My  questions  to  instrument  makers  on  these 
points  were  as  follow  : — (a.)  What  distance  above  the  knee-level 
should  be  left  by  the  stump  in  order  to  give  room  for  the  mechanism 
of  an  artificial  knee-joint  ?  (b.)  Do  you  find  any  difficulty  in 
fitting  a  good  substitute  limb  to  the  stump  of  a  Garden's  amputa- 
tion, or  do  you  prefer  the  stump  of  an  amputation  through  the 
thigh  at  the  lower  third  ?  The  answers  to  these  will  be  best  taken 
together,  as  they  throw  light  on  the  other.  Taking  first  those 
makers  who  prefer  amputatioTis  above  the  knee-joint : — 

I.  answered  {a.)  Fully  3  inches  above  the  centre  of  the  knee- 
joint,  (b.)  We  can  fit  a  good  substitute  limb  in  a  case  of  Garden's 
amputation,  but  it  requires  outside  steel  joints.  We  prefer,  there- 
fore, the  amputation  to  be  at  the  lower  third  of  the  thigh,  as  it 
allows  of  a  solid  joint,  which  is  lighter  and  neater. 

III.  answered  (a.)  It  should  be  3  inches.  (6.)  Garden's  amputa- 
tion is  unsatisfactory  where  a  knee-joint  is  required,  and  we  have 
no  difficulty  in  applying  an  artificial  leg  with  ankle  and  knee  joints 
when  amputated  at  about  lower  third. 

IV.  answered — The  artificial  limbs  we  supply  will  allow  of 
1  inch  above  the  centre  knee,  though  we  prefer  amputation  about 
the  middle  of  femur.  The  amputation  at  knee-joint  is  not  good  ; 
we  make  an  artificial  leg  for  this  amputation.  The  upper  bracket 
must  be  longer  than  the  sound  leg,  or  it  can  be  made  the  same 
length  by  putting  steel  joints  at  sides  of  knee — a  great  disad- 
vantage, as  the  rivets  of  knee-joint  soon  wear  loose  and  rattle. 
The  amputation  through  the  thigh  at  lower  third  is  a  good  am- 
putation for  all  kinds  of  artificial  substitutes. 

No.  V.  {a.)  "  In  the  case  of  a  man  5  feet  7  inches,  about  4  inches 
above  the  knee.  (6.)  For  mechanical  reasons,  amputations  through 
the  joints  prevent  the  mechanism  from  constructing  an  efficient  or 
durable  joint.  .  .  .  For  working  man,  with  no  desire  to  bend 
his  knee,  a  Garden's  amputation  is  admirable." 

No.  VI.  (a.)  "  Five  inches  quite  enough.  {b.)  My  favourite 
operation  is  just  above  the  condyles ;  and  had  I  to  be  operated 
upon,  would  select  this  operation  before  lower  third  of  thigh,  or 
even  seat  of  election." 


1889.]         MR   CIIAKLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.  825 

No.  VIII.  {a.)  "Four  and  a  half  inches.  (&.)  I  prefer  the 
amputation  through  thigh  at  lower  third ;  in  my  opinion^  the  best 
walkers  are  amputated  there  (both  above  and  below  the  knee  re- 
spectively)." 

No.  IX.  "  Amputations  through  the  knee-joint  are  undesirable, 
for  the  fact  that  the  remaining  portion  is  usually  very  sensitive  to 
the  touch  of  anything;  also  being  larger  at  the  circumference  than  at 
a  point  2  inches  above,  it  necessitates  a  very  ugly-looking  artificial, 
and  gives  more  or  less  annoyance  to  the  wearer.  An  amputation 
2  inches  above  tlie  knee-joint  leaves  sufficient  room  for  the  arti- 
ficial knee.  Notwithstanding  these  objectional  cases  of  amputa- 
tion to  which  I  have  alluded,  we  adjust  artificials  to  them  in  such 
a  manner  that  the  patient  walks  very  well." 

No.  XII. — "Never  amputate  through  the  knee-joint,  but  3 
inches  from  tlie  knee-joint.  An  amputation  through  the  knee,  or 
only  removing  tuberosity  of  femur,  renders  me  incapable  of  fitting 
it  with  either  a  leg  for  above  or  a  leg  for  below  knee  amputation. 
I  have  no  room  for  forming  an  artificial  knee-joint  nor  any  lower 
stump  to  articulate  lower  part." 

Three  of  the  answers,  however,  were  favourable  to  amputations 
through  or  dose  to  the  joint.  No.  II.  writes,  "  It  is  not  necessary 
to  leave  any  space  between  the  knee-joint  and  stump  for 
mechanism,  because  if  the  amputation  was  through  the  joint  or 
just  above  it,  the  artificial  joints  would  be  arranged  to  go  outside 
or  on  each  side  of  the  end  of  the  stump." 

No.  VII.  says,  "We  find  no  difficulty  whatever  in  fitting  a  limb 
to  any  case  of  amputation  from  the  knee-level  upwards,  providing 
some  stump  is  left.  In  our  designs  we  modify  the  artificial  knee- 
joint  according  to  the  point  of  operation.  When  there  is  no 
section  of  the  bone  shaft,  a  bearing  can  be  obtained  over  the  end 
of  the  stump,  especially  if  there  is  a  good  flap  well  brought  up  out 
of  the  way.  When  this  is  the  case,  much  less  weight  is  borne 
laterally  by  the  stump,  and  the  usual  wasting  of  the  adipose  and 
muscular  tissue  to  some  extent  lessened.  Both  Garden's  and 
Pollock's  amputations  are  excellent.  It  is  certainly  an  advantage 
to  leave  the  patella  if  well  covered  and  firmly  disposed. 

No.  X. — The  advantage  of  having  the  end  of  the  femur  to  bear 
upon  more  than  offsets  the  disadvantage  of  the  extra  elongation  of 
the  artificial  thigh  in  order  to  place  the  mechanism  of  the  knee 
below  the  stump ;  therefore  we  advise  the  disarticulation  of  the 
knee.  If  the  amputation  is  to  be  made  above  the  knee  articula- 
tion, there  is  no  advantage  in  amputating  less  than  about  3  inches 
from  the  knee-level.  We  are  not  in  favour  of  trimming  the  con- 
dyles in  knee-joint  amputations.  We  rather  prefer  them  in  a 
healthy  stump,  as  they  afford  us  means  for  securing  the  leg  to  the 
stump  with  less  shoulder  suspension." 

As  the  weight-bearing  capabilities  of  stumps  form  an  element  in 
the  varying  opinions  just  quoted,  it  may  be  well  here  to  quote  my 

EDINBURGH    MED.    JOUHN..    VOL.    XXXIV.  — MO.    IX.  5  M 


826  MR   CIIAllLES   W.    CATIICA15T   ON   ARTIFICIAL   LIMBS.      [MARCH 

next  question,  and  the  answers  to  it.  It  ran  thus:  "Can  you 
frame  any  general  conclusions  as  to  the  frequency  with  which  the 
'  bearing '  can  be  taken  on  the  face  of  a  stump,  or  upon  the  limb 
just  above  it  ? " 

No,  I.  "We  find  it  very  seldom  that  the  wliole  weight  can  be 
borne  on  the  face  of  the  stump,  but  we  often  put  in  a  pad  to  bear 
a  portion  of  the  weiglit." 

No.  11.  "It  is  not  often  that  pressure  can  be  borne  on  the  end 
of  the  stump.  Syme's  amputation  admits  of  it.  Amputation 
through  knee-joint  also  allows  of  the  weight  being  borne  to  a  cer- 
tain extent  on  end  of  stump  aided  by  support  at  top  of  socket," 

No.  III.  "It  is  very  seldom  that  patients  can  bear  any  pressure 
on  end  of  stump  for  at  least  twelve  months  after  operation,  but 
any  amount  of  pressure  at  buttock  or  tubercle  of  tibia." 

No.  IV.  "  It  is  my  general  practice  not  to  take  any  bearing  on 
the  end  of  stump ;  there  is  only  one  that  I  know  out  of  hundreds 
that  have  been  under  my  care  that  can  take  his  bearing  on  end  of 
stump,  and  that  only  partial.  The  principal  bearing  being  taken 
round  thigh,  the  stump  becomes  tender  and  sore,  but  to  take 
bearing  on  the  tuberosity  of  the  ischium." 

No.  V,  "  No  artificial  limb  can  be  constructed  so  as  to  safely 
permit  pressure  upon  the  end  of  the  bone.  The  art  consists  in 
adapting  mechanical  aid  to  surrounding  ])arts  so  as  to  relieve  the 
end  from  all  pressure.  Tlie  stump  should  bear  most  pressure  in 
thigh  and  leg  amputations." 

No.  VI.  "  Nearly  every  Syme's,  and  when  through  the  con- 
dyles." 

No.  VII.  "  "Wherever  it  is  absolutely  necessary  to  saw  through 
the  bone  shaft,  no  reliance  can  be  placed  upon  the  possibility  of 
taking  the  weight  upon  tlie  end." 

No.  VIII.  "Except  in  a  Teale's  or  a  Syme's  amputation,  I 
have  the  bearing  brought  around  limh,  though  occasionally  the 
pressure  may  be  divided  between  face  of  stump  and  the  limb  above 
it." 

No.  IX.  does  not  refer  to  this  point. 

No.  X.  "  In  disarticulations  (either  ankle  or  knee)  we  can 
almost  invariably  bear  on  the  face  of  the  stump,  but  in  amputa- 
tions through  the  shafts  of  the  bone,  pressure  can  rarely  be  taken 
on  the  face,  only  in  cases  where  the  extremity  of  the  bone  has  a 
good  periosteal  covering,  and  the  fiaps  are  not  adherent  to  the 
bone." 

If  we  now  sum  up  the  discussion  on  amputations  through  or 
above  the  knee,  we  find  that  only  a  certain  number  of  artificial 
limb  makers  agree  in  calling  for  amputations  well  above  the  joint, 
and  that  their  reasons  are — 

(1.)  Want  of  room  for  mechanism. 

(2.)  Clumsy  appearance  of  the  new  limb,  which  must  go  outside 
the  stump. 


1889.]         MR   CHARLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.  827 

Against  this  view  we  find  other  makers  holding — 

(1.)  That  the  difference  in  mechanism  is  not  of  much  importance. 

(2.)  That  any  such  disadvantage  that  may  exist  is  more  than 
compensated  for  by  the  increased  bearing  power  of  a  bone  section 
through  an  articular  end,  and  by  the  better  grasp  that  the  new 
limb  can  be  made  to  take  above  the  broadened  articular  extremity, 
and  so  to  allow  shoulder  suspension  in  part  or  completely  to  be 
dispensed  with. 

4.  Personally,  I  have  had  no  experience  of  stumps  at  the  knee- 
joint  or  just  above  it  which  have  been  fitted  with  working  knee- 
joints.  But  from  the  statements  of  the  makers  quoted,  from  the 
usefulness  of  rule-joint  knees  in  lower  amputations,  and  from  d 
priori  considerations,  I  can  see  no  reason  to  depart  fi-om  the 
conservative  principles  already  laid  down. 

Before  closing  this  paper,  I  wish  briefly  to  consider  some  of  the 
details  of  mechanism  of  artificial  joints  for  which  limb-makers  ask 
us  to  sacrifice  so  much. 

1.  Rale  or  Side  Joints  v.  Joints  ivith  a  Transverse  Axis. — Here 
I  would  be  willing  to  grant  some  advantage  to  the  latter,  but,  as 
already  stated,  not  an  advantage  which  may  be  taken  into 
account. 

2.  Artificial  Ankle-joint. — Very  much  labour  and  ingenuity  has 
been  expended  over  various  forms  of  artificial  ankle.  I  cannot  see 
that  even  the  best  possible  form  of  artificial  ankle-joint  has  any 
advantage  except  in  appearance  over  the  curved  sole  and  rigid 
foot-piece  essentially  introduced  by  Count  Beaufort.  Inventors  who 
pride  themselves  upon  the  exactness  with  which  they  have  imitated 
the  natural  ankle-joint,  forget  that  the  chief  features  of  the  natural 
joint  are  the  muscles  and  tendons  which  actively  control  its  move- 
ments. 

The  trajectory  of  the  knee  in  natural  walking  is  nearly  in  a 
straight  line  (Fig.  3,  G  Gi),  and  an  examination  of  the  movements 
which  bring  this  about  show  that  a  varying  combination  of  move- 
ments between  the  knee,  ankle,  and  foot  are  needed,  such  that  no 
mechanism  can  imitate. 

If  we  consider,  how^ever,  how  else  the  straight  line  trajectory  of 
the  knee  could  be  brought  about  besides  by  active  living  joints,  we 
will  easily  see  that  a  curved  sole  would  do  it. 

If  the  foot  roll  on  an  arc  of  a  circle  whose  centre  is  at  tlie  knee- 
joint,  it  will  be  easy  to  see  that  the  knee  will  be  kept  as 
steadily  in  a  straight  line  as  the  axle  of  a  wheel  would  be ;  the 
length  of  step  will  be  less,  but  the  evenness  of  gait  will  be  much 
the  same  as  in  nature,  and  this  has  been  found  in  patients . 
wearing  the  Beaufort  leg. 

If  we  contrast  this  with  wliat  occurs  in  the  artificial  tendo 
Achilles  legs,  we  will  find  a  very  different  result.  The  two  com- 
binations possible  and  invariable  with  this  mechanism  are  the 
simultaneous  flexion  and  extension  of  the  knee  and  ankle. 


828  MR   CHARLES   W.   CATHCART   ON   ARTIFICIAL   LIMBS.     [MARCH 

The  combined  flexion  is  useful  for  clearing  the  ground  as  the 
limb  is  being  carried  forward  after  one  step  to  begin  the  next,  but 


Fig.  3. — After  Professor  M.  Marey's  diagram  in  liis  paper, "  Analyse  cindmatique  de  la  marclie," 
Comptes  rendus,  19th  May  1884. 

the  combined  extension  of  the  two  joints  necessitates  an  unnatural 
trajectory  of  the  knee,  and  thus  a  considerable  disturbance  of  the 
gait.  While  the  artiticial  foot  is  on  the  ground,  the  whole  limb 
pivots  round  a  centre  corresponding  to  the  balls  of  the  toes. 

If,  on  the  other  hand,  there  be  a  movable  artificial  ankle-joint 
without  any  tendo  Achilles,  the  pivoting  occurs  at  this  joint  instead 
of  at  the  ball  of  the  toes. 

In  either  case  the  knee  must  pass  through  an  arc  of  a  circle 
(whose  centre  is  at  the  ball  of  the  artificial  toes  or  at  the  ankle 
respectively),  and  the  gait  be  altered  accordingly. 

Many  limb-makers  pride  themselves  on  a  lateral  movement  of 
the  foot.  This  some  of  them  ignorantly  put  at  the  ankle-joint ; 
but  even  when  it  is  put,  as  a  few  do,  mid-way  in  the  foot,  I  am 
doubtful  if  the  gain  is  as  great  as  is  alleged. 

Putting  these  points  together,  there  is  no  real  advantage  in 
walking  to  be  gained  by  making  the  artificial  knee  and  ankle 
joints  work  together  by  a  tendo  Achilles — therefore  no  room  need 
be  left  for  any  part  of  this  mechanism  above  the  level  of  the  knee. 
Similarly  at  the  ankle,  mechanism  for  a  complicated  joint  need  not 
be  allowed  when  a  simple  curved  sole  will  do  as  well  and 
better  than  any  artificial  joint.  Moreover,  if  lateral  play  of  the 
foot  be  wanted,  the  mechanism  for  it  might  surely  be  provided  for 
in  the  foot  itself. 

Since  the  curved  sole  does  not  look  very  well,  I  am  trying  to 
devise  a  foot  with  a  curved  sole  the  fore  part  of  which  will  flatten 
out,  when  not  pressed  on,  to  save  appearances, 

I  am  greatly  indebted  to  those  makers  of,  and  dealers  in  arti- 
ficial limbs  who  have  so  kindly  replied  to  my  questions,  and  I  now 
append  a — 


1889.]         MR   CHARLES   W.    CATHCART   OJv^   ARTIFICIAL   LIMBS.  829 

List  of  Authorities  referred  to. 

1.  H.  Hilliard  &  Sou,  7  Nicolsoii  Street,  Edinburgh  (Dealer). 

2.  Archibald   Youug,   57   aud    61    Forrest    Eoad,    Edinburgh 
(Dealer). 

3.  J.  Gardner,  32  Forrest  Eoad,  Edinburgh  (Dealer). 

4.  K.  E.  Schram,  6  Princes  St.,  Cavendish  Sq.,  London  (Dealer). 

5.  J.   Critchley,  88  Upper  Pitt  Street,  Great   George   Street, 
Liverpool  (Maker). 

6.  J.  Scotland,  Springburn,  Glasgow  (Maker). 

7.  M.  Masters  &  Sons,  210  New  Kent  Eoad,  London  (Maker). 

8.  D.  E.  Corcoran,  124  Stephen's  Green,  Dublin  (Maker). 

9.  W.  J.  Stickle,  658  Broadway,  New  York  (Maker). 

10.  A.  A.  Marks,  701  Broadway,  New  York  (Maker). 

11.  H.  J.   Stump,  53   Bolsover   Street,  Great  Portland   Street, 
London  (Maker). 


CLINICAL  REPORTS  OF  CASES 

Under  tlie  care  of  Mr  John  Duncan,  Surgeon  to  the  Royal  Infirmary, 

Edinburgh. 

Caries  of  Vertebra;  Paralysis;  Operation;  Cure. 

J.  W.,  set.  11,  Friockheim,  near  Arbroath.  Admitted  23rd 
October  1888  on  recommendation  of  Dr  Kelly.  The  father  died 
of  pleurisy.    The  patient  has  had  the  usual  children's  ailments  only. 

Tlie  illness  is  attributed  to  a  severe  fall  in  the  autumn  of  1886, 
but  a  doctor  was  not  consulted  till  July  1887.  Notwithstanding 
treatment  he  steadily  got  worse  from  that  time,  and  in  December 
1887  began  to  feel  numbness  in  his  legs  and  even  as  high  as  the 
abdomen.  By  March  1888  the  paraplegia  had  become  complete 
and  has  remained  so.  ""  ^ 

0)1  Admission. — Temp.,  98"°2  ;  pulse,  120  ;  resp.,  18  ;  urine, 
1025,  slight  mucous  cloud,  otherwise  normal.  In  the  mid-dorsal 
region  of  the  spine  there  is  a  very  marked  angular  curvature.  The 
lower  limbs  as  higli  as  the  groin  are  nearly  absolutely  paralyzed. 
He  can  feel  nothing,  and  can  only  move  very  slightly  the  great  toe 
of  the  right  foot.  Tlie  paralysis  is  of  the  usual  spastic  variety. 
He  has  control  over  the  bowels  and  bladder. 

Oct.  31. — Mr  Duncan  removed  the  spines  and  laminae  of  the 
fourth,  fifth,  sixth,  and  seventh  dorsal  vertebrae.  The  membranes 
were  found  adhering  to  the  bones  by  granulation  texture,  which 
was  easily  scraped  from  them  by  means  of  the  sharp  spoon.  They 
then  appeared  tolerably  white  and  smooth.  Only  after  this  was 
done  could  a  faint  pulsation  be  observed  in  the  cord,  but  the  canal 
above  and  below  was  now  found  quite  free  and  in  no  way  com- 
pressing the  contained  viscus.  A  plaster-of-Paris  jacket  was 
applied. 


830  CLINICAL   REPORTS   OF   CASES,  [mAUCH 

Nov.  2. — An  aperture  was  cut  opposite  the  wound,  and  the 
drainage-tube  removed.  He  could  move  his  feet  at  the  ankles,  and 
sensation  had  returned  to  the  extent  that  he  could  recognise  a 
moderately  firm  touch,  but  could  not  localize  it. 

Nov.  6. — The  wound  at  the  second  dressing  is  absolutely  healed. 
He  can  slightly  move  his  right  knee. 

Nov.  13. — He  can  localize  a  light  touch  with  tolerable  accuracy, 
and  can  easily  move  his  legs  throughout. 

From  this  time  slow  but  steady  improvement  has  gone  on,  till 
on  4th  January  he  was  able  to  stand,  and  on  14th  January  to  walk 
a  few  paces  unsupported.  He  is  still  (15th  February)  steadily 
improving,  a  poroplastic  case  having  been  substituted,  on  21st 
January,  for  the  plaster-of-Paris,  to  diminish  the  weight.  We 
keep  him  yet  mainly  in  the  horizontal  position.  His  sensation  is 
now  very  good,  but  he  still  walks  with  a  spastic,  jerky  gait. 

Remarks. — It  is  right  that  this  case  should  be  published,  as 
further  confirmation  from  an  independent  source  of  the  value  of 
Mr  M'Evven's  suggestion  for  the  relief  of  paraplegia  due  to  caries 
of  the  vertebrae.  A  sufficient  time  seems  to  have  elapsed  to  prove 
the  permanence  of  the  success.  I  must  say  that  I  approached  the 
operation  with  hesitation,  on  account  of  the  long  duration  and 
completeness  of  tlie  paralysis.  The  fear  was  that  the  inflammatory 
action  mioht  have  so  disorganized  the  tissues  of  the  cord  as  to 
make  their  recovery  impossible.  Possibly  this  was  so  to  a  certain 
extent,  and  it  may  be  that  absolute  health  will  never  be  recovered; 
but  improvement  is  yet  going  on,  and  at  the  worst  it  is  no  small 
matter  to  have  restored  sensation  and  the  power  of  walking  in  a 
case  so  far  advanced.  It  seems  to  me  that  the  operation  properly 
conducted  may  now  be  considered  not  only  as  feasible,  but  as  a 
safe  and  useful  addition  to  surgical  procedure. 


Three  Casks  of  Fracture  of  the  Spine  ;  Paralysis  ;  Operation. 

Case  I.— E.  G.,  fet.  19,  admitted  8th  March  1888.  The  patient 
fell  from  a  tree  about  30  feet.  He  cannot  tell  what  part  he  struck. 
He  found  himself  at  once  unable  to  rise. 

On  admission  there  was  found  to  be  complete  loss  of  motion  and 
sensation  from  the  groin  downwards.  There  was  also  retention  of 
urine.  The  spine  of  the  eleventh  dorsal  vertebra  was  movable,  and 
projected  somewhat. 

An  incision  was  made  in  the  middle  line,  and  the  spine  of  the 
eleventh  dorsal  vertebra  was  found  to  be  separated  by  a  fracture 
through  the  laminae.  The  neural  arches  of  the  tenth  and  twelfth 
were  also  taken  away,  as  they  were  broken,  and  the  tenth  especially 
forced  in  upon  the  cord.  A  line  of  fracture  was  now  seen  to  run 
between  the  tenth  and  eleventh  vertebrae,  and  the  body  of  the  tenth 
was  displaced  forward  with  relation  to  the  eleventh,  but  only  to  a 
slight  extent — say  about  a  quarter  of  an  inch.  It  was  now  certain 
that  the  cord  had  been  freed  from  all  pressure ;  and  as  the  mem- 


1880.]  BY   MR   JOHN    DUNCAN.  831 

branes  were  quite  uninjured,  the  wound  was  sewed  up  and  a 
drainage-tube  inserted. 

March  10. — Drainage-tube  removed. 

March  17. — Wound  absolutely  healed  at  second  dressing.  A 
very  slight  improvement  in  sensation. 

March  22. — Incontinence  of  urine  has  come  on.  No  improve- 
ment in  motion  or  sensation. 

The  condition  of  the  patient  remained  the  same,  the  general 
health  being  perfect,  but  the  paraplegia  as  complete  as  before,  until 
he  was  removed  after  six  months  to  the  Longraore  Hospital  for 
incurables. 

Cask  II.— a.  M'G.,  tet.  34,  admitted  21st  January  1889.  The 
patient  was  unable  to  give  any  history  of  the  accident,  but  it  was 
reported  to  have  been  the  result  of  a  fall  of  shale  in  a  mine.  The 
patient  had  been  subject  to  asthma. 

On  admission  the  back  was  found  much  bruised,  and  ecchymosed 
in  its  upper  part.  The  eighth  rib  on  the  right  side  was  broken  at 
the  angle.  There  was  very  marked  projection  of  the  third  lumbar 
spine,  complete  paraplegia,  and  retention  of  urine.  He  was  in  a 
state  of  extreme  collapse. 

Jan.  22. — His  condition  was  much  improved,  the  pulse  being 
full  and  strong.  He  complains  greatly  of  pain  in  the  injured  por- 
tion of  the  back,  and  of  pain  on  taking  a  full  breath,  referred  to  the 
fractured  rib.  Mr  Dnncan  cut  down  on  the  prominent  spine,  and 
finding  it  detached  by  fracture  through  the  laminte,  removed  it.  The 
arcli  of  the  second  lumbar  vertebra  was  also  removed.  It  was  now 
seen  that  the  body  of  the  second  was  displaced  forward  to  the  extent 
of  nearly  an  inch  in  relation  to  the  third.  The  slieath  looked  blue 
and  distended.  It  was  opened,  and  some  blood-clots  and  bloody 
fluid  evacuated.  Tiie  cauda  appeared  to  be  little  injured,  so  the 
sheath  was  stitched.  It  was  now  found  to  be  possible  by  manipu- 
lation to  replace  the  vertebrcC  in  position,  and  thev  were  so  retained 
by  putting  a  large  pad  across  the  upper  part  of^ie  abdomen  and 
the  lower  ribs  while  the  patient  lay  prone  in  a  hammock.  A 
plaster-of-Paris  jacket  was  then  applied. 

In  the  evening  he  coi]jplained  much  of  the  prone  position,  and 
made  attempts  to  turn  over  and  even  get  out  of  the  couch.  Sub- 
cutaneous injection  of  morphia  was  given,  after  which  he  slept. 

Jan.  23. — The  wound  was  examined  and  seemed  to  be  healed 
throughout.  The  temperature  was  normal  and  the  pulse  good. 
Sensation  had  returned  in  the  legs  to  considerably  below  the  knees. 
In  the  evening  he  again  became  very  agitated  and  restless,  com- 
plaining loudly  of  his  posture,  and,  notwithstanding  morphia, 
tossed  much  about  during  the  night.  Towards  morning  the 
breathing  became  suddenly  much  embarrassed,  and  the  house- 
surgeon  was  called  up  and  placed  him  in  the  dorsal  position.  This 
gave  little  relief,  and  he  cjiied  in  the  early  morning,  having 
become  quickly  cyanosed. 


832 


CLTXICAL    PEPOUTS    OF   CASKS, 


MARCH 


Sectio  Cadaveris. — The  left  leaf  of  the  diaphragm  was  largely 
lacerated,  and    the  stomach  (somewhat  dilated)  and    the   great 

omentum  lay  in  the  left 
pleural  cavity.  The  left 
lung  was  compressed  and 
the  heart  displaced  to 
the  right.  There  was 
a  fracture  of  the  base 
of  the  seventh  cervical 
spinous  process.  The 
lumbar  region  was  found 
as  described  after  the 
operation,  the  wound 
being  adherent  through- 
out  and  the  displacement 
of  vertebrae  perfectly  re- 
duced. One  or  two  strands 
of  the  Cauda  were  bruised, 
but  otherwise  the  cord 
was  healthy. 

Casii;  III. — R.  S.,  £et.  21,  Lochgelly.  Admitted  25th  December 
1888.  He  was  working  that  day  in  a  coal-pit  when  a  mass  of 
coal,  estimated  at  10  cwt.,  fell  from  the  roof,  a  height  of  three  feet, 
and  struck  him  on  the  back  while  he  was  in  a  stooping  posture. 
When  he  was  released  he  found  that  he  had  lost  motion  and 
sensation  in  his  legs.  His  water  was  drawn  off  as  he  could  not 
pass  it,  and  he  was  sent  to  the  Infirmary. 

There  was  found  to  be  immense  extravasation  over  the  back 
from  the  second  dorsal  vertebra  to  the  sacrum,  and  a  marked  pro- 
jection of  the  spine  of  the  second  lumbar  vertebra,  with  a  hollow 
above.  The  paraplegia  was  absolute  and  complete  as  high  as  the 
groin.  He  did  not  feel  the  passing  of  the  catheter.  The  patient 
was  much  collapsed. 

It  was  found  to  be  impossible  to  diminish  the  deformity,  and  in 
consequence  of  the  condition  of  the  patient  and  the  enormous 
extravasation,  it  was  thought  unadvisable  to  operate  at  the  time  of 
admission. 

Jan.  13,  1889. — The  patient  has  slowly  rallied.  Six  ounces  of 
fluid  blood  were  to-day  aspirated  from  the  back. 

Jan.  30. — The  back  is  now  well,  showing  the  deformity  more 
clearly.  The  paraplegia  is  as  complete  as  before.  As  is  usual,  the 
retention  of  urine  and  fteces  has  passed  into  incontinence.  Mr 
Duncan  removed  first  the  fractured  spine  and  lamina  of  the  second 
lumbar  vertebra.  Parts  were  found  to  be  so  matted  together  as  to  be 
scarcely  recognisable,  but  after  the  removal  of  two  other  arches  it 
was  seen  that  the  whole  of  the  first  lumbar  vertebra  was  displaced 
forwards  about  an  inch,  and  that  th^  cord  was  torn  half  through 
and  made  two  bends,  each  perfectly  rectangular,  at  the  upper 


1889.]  BY  ME  JOHN   DUNCAN.  833 

surface  of  the  second  lumbar  vertebra  following  the  line  of 
fracture.  Above  the  injured  part  the  cord  was  gently  loosened 
from  its  bed,  and  stitched  by  three  fine  catgut  sutures  to  the 
portion  below  the  seat  of  injury  by  means  of  the  sheath,  the 
injured  part  being  thus  put  in  a  state  of  relaxation.  In  doing  this 
some  cerebro-spinal  fluid  leaked  away.  The  operation  was  a  very 
tedious  and  difficult  one  from  the  impossibility  of  recognising 
textures  either  from  appearance  or  relations. 

Feb.  1. — There  has  been  very  persistent  sickness  since  the 
operation,  but  this  has  passed  off,  and  the  patient  has  now  rallied 
well,  the  temperature  and  pulse  being  normal.  There  has  been 
steady  flow  of  cerebro-spinal  fluid  through  the  drainage-tube, 
which  is  now  removed. 

Feb.  4. — The  patient  has  in  every  respect  done  extremely  well, 
except  that  the  wound  has  had  to  be  dressed  daily  on  account  of 
the  copious  flow  of  cerebro-spinal  fluid  through  the  opening  where 
the  drainage-tube  had  been,  and  from  other  points  between  the 
sutures.  Attempts  have  twice  been  made  to  arrest  this  by  horse- 
hair stitches,  but  without  success.  For  two  days  he  has  com- 
plained much  of  headache.  To-day  more  stitches  supported  by 
strapping  have  been  introduced,  the  foot  of  the  bed  has  been 
elevated,  and  the  patient  placed  again  in  the  prone  position.  This 
position  was  originally  tried,  but  given  up  on  his  urgent  remon- 
strance. 

Feb.  6. — The  flow  of  fluid  has  much  diminished,  and  the  wound 
has  not  required  dressing  for  two  days.     The  temperature,  however,  ( 

rose  last  night  to  101°;  it  had  not  before  that  time  exceeded  99°.  ^'^ 

Feb.  15. — The  cerebro-spinal  fluid  still  flows,  but  in  diminished  x 

quantity.     The  loss  is  yet  estimated  as  at  least  2  ounces  each  day,  \ 

The  temperature  is  nearly  normal,  and  the  patient  is  otherwise  ^ 

well,  but  the  paraplegia  is  unaltered. 

Remarks. — The  propriety  of  operating  in  cases  of  fracture  of  the 
spine  has  not  yet  been  decided,  and  the  three  cases  recorded  are  a 
contribution  to  the  determination  of  the  question.  I  put  it  to 
myself  thus  before  I  operated :  Eecovery  in  these  men  is  hope- 
less ;  death  as  a  direct  result  in  a  shorter  or  longer  time  probable ; 
the  cause  of  the  paralysis  is  presumably  compression,  and  the 
operation  cannot  in  itself  be  highly  dangerous.  I  have  not  been 
successful,  but  I  think  that  there  are  valuable  deductions  to  be 
drawn  from  these  cases,  and  that  they  do  afford  justification  for 
further  attempts. 

The  most  disappointing  was  certainly  the  first,  in  which  every- 
thing went  as  could  be  wished,  and  yet  the  paralysis  did  not 
improve.  The  most  encouraging  was  the  second,  in  which  sensa- 
tion had  greatly  returned  and  the  wound  had  healed,  although  the 
patient  died  from  an  unsuspected  rupture  of  the  diaphragm,  through 
which  his  restless  struggles  had  evidently  suddenly  forced  his 
stomach   and   omentum.      The   third  case  is  yet  unfinished,  but 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.   IX.  5  N 


834  CLINICAL   KEPOIiT   OF   CASK,  [MARCH 

although  it  is  so  I  have  brought  it  forward  with  the  others  as 
showing  one  of  the  sources  of  danger  in  the  operation, — the  escape 
of  cerebro-spinal  fluid.  Of  this  there  can  be  no  fear  if  the 
membranes  are  entire,  or  even  if  recently  torn.  To  stitch  them 
up  ought  to  be  quite  sufficient  if  the  wound  be  kept  aseptic.  But 
in  this  case,  seven  weeks  after  the  accident,  it  was  impossible  to 
recognise,  much  less  to  stitch  up,  the  membranes  for  a  considerable 
space  above  and  below  the  fracture. 


CLINICAL  REPORT  OF  CASE  AT  LEITH  HOSPITAL 

Under  the  Care  of  Dr  J.  Allan  Gray, 

Case  of  Intrathoracic  Tumour.^ 

John  M'E.,  aged  43,  a  labourer,  was  admitted  on  the  4th  October 
1888,  complaining  of  pain  in  the  left  shoulder  and  left  side,  and  of 
inability  to  follow  his  occupation. 

Examination  on  admission  failed  to  elicit  any  well-marked 
ailment  beyond  the  presence  of  a  rheumatic-like  pain  in  the 
shoulder  and  some  tenderness  over  the  terminations  of  the  sixth 
intercostal  nerve  of  the  left  side.  He  was  consequently  or- 
dered — 

1^     Pot.  Bromid.,  ,         ,         3vj. 

Tr.  Nucis  vomicae,  .         3ij- 

Infus.  Calumba?  ad.,        .         §vj.     S.  et  M. 
Sig. — §ss.  ter  in  die. 

During  the  fortnight  which  elapsed  between  the  patient's 
admission  and  the  beginning  of  the  winter  session  no  pronounced 
change  in  the  symptoms  occurred.  As  the  pain  continued  during 
this  time,  a  blister  was  on  the  8th  October  applied  at  the  level  of 
the  sixth  and  seventh  vertebrae,  close  to  the  spinal  column  behind  ; 
and  on  the  12th  October  a  menthol  plaster  was  placed  over  the 
site  of  pain  in  the  axillary  region. 

October  17. — Patient  examined  with  great  care,  but  nothing 
further  elicited  except  the  presence  of  a  slight  condensation  at 
the  apex  of  the  right  lung.  This,  however,  was  of  old  standing 
and  quiescent.  The  history  of  the  case,  as  now  obtained,  showed 
that  the  patient  had  been  abroad,  had  had  an  attack  of  jaundice 
eighteen  years  ago  when  in  America,  and  had  had  two  attacks  of 
bronchitis.  The  present  illness  began  about  eight  months  ago 
with  a  feeling  of  cold  and  of  pain  all  over  the  body,  and  especially 
in  the  left  shoulder.  The  pains  in  the  body  disappeared  after 
treatment,  but  the  pain  in  the  shoulder  has  persisted.  During 
the  first  six  months  this  pain  was  not  constant,  and  did  not  pre- 
vent him  working.  But  at  the  end  of  that  time  it  became  so 
severe  as  to  confine  him  to  bed.  A  week  later  he  began  to  suffer 
from  the  violent  pain  in  the  left  side  of  the  chest  of  which  he  now 

*  From  the  notes  of  Miss  A.  W.  Jagannadham,  clinical  clerk. 


1889.]  BY   DK   J.    ALLAN    GRAY.  835 

complains.  A  provisional  diagnosis  of  intercostal  neuralgia  of 
possibly  malarial  origin  was  now  made,  and  as  the  patient  was 
pale  and  anaemic,  he  was  accordingly  ordered — 

IJ;     Tinct.  Ferri  perchloridi,         .         Siij. 
Liq.  Arsenici  hydrochlor.,      .         3j. 
Ext.  Cascarse  sagradse  liquidi,         §ss, 
Aq.  ad.,         ....         §vj.     Misce. 
Sig. — §ss.  t.   d.  s.,  ex  aq.  post,  cib.,  and  to  have,  when  needed,  a 
hypodermic  injection  of  morphia  over  the  painful  spots. 

Noverriber  1. — Since  last  note  no  great  change  has  occurred. 
The  patient  was  again  carefully  examined  as  to  the  condition  of 
his  brain  and  spinal  cord,  but  without  anything  abnormal  being 
found  beyond  great  taciturnity.  The  circulatory  and  urinary 
systems  are  quite  normal,  and  there  has  not  been  any  noticeable 
rise  of  temperature  since  admission. 

Novemler  9. — A  little  glandular  swelling  was  to-day  observed  in 
the  left  axilla  ;  and  the  patient  was  again  examined,  with  the  fol- 
lowing result : — 

Hoeynopoietic  System. — Immediately  above  the  clavicle  there  is 
an  undefined  hardness,  painful  on  pressure,  and  apparently  of  a 
glandular  cliaracter.  At  the  outer  edge  of  each  sterno-mastoid 
muscle,  and  about  an  inch  and  a  half  above  the  clavicle,  there  is 
an  enlarged  gland.  There  is  likewise  an  enlarged  and  somewhat 
painful  gland  in  the  left  axilla,  and  a  circumscribed  thickening  of 
the  tissues  in  the  median  line  of  the  neck  posteriorly  about  two 
inches  below  the  external  occipital  protuberance. 

The  spleen  is  normal  in  size  and  position.  The  red  blood  cor- 
puscles number  4,600,000  per  cubic  millimetre ;  and  there  is  no 
increase  of  white  corpuscles. 

Locomotory  System. — Patient  complains  of  pain  in  the  left 
shoulder-joint,  increased  by  movement.  The  fore-arm  is  kept 
flexed  almost  at  a  right  angle  with  the  arm.  There  is  a  distinct 
fulness  extending  from  the  left  acromion  down  to  the  anterior  fold 
of  the  axilla. 

Respiratory  System. — Eespirations  20  per  minute,  of  thoraco- 
abdominal type.  No  pain  or  difficulty  on  taking  a  deep  breath. 
Slight  paroxysmal  cough,  which  is  most  troublesome  in  the  morn- 
ing, and  aggravates  the  pain  in  the  left  side.  It  is  accompanied 
by  viscid  expectoration.    The  thorax  bulges  somewhat  to  the  right. 

On  inspection  there  is  anteriorly  a  marked  fulness  in  the  left 
supra-  and  infra-clavicular  regions,  and  a  greater  range  of  chest 
movement  on  the  right  side.  Posteriorly  the  left  scapula  is  raised, 
and  its  vertebral  border  tilted  upwards  and  outwards.  There  is  a 
slight  fulness  in  the  left  interscapular  region,  and  the  left  shoulder 
is  raised.  On  the  right  side  there  is  a  slight  depression  in  the 
supra-spinous  fossa. 

Palpation  corroborates  inspection  as  to  the  ampler  movement  of 
the  right  side,  both  anteriorly  and  posteriorly.     There  is  consider- 


83G  CLINICAL  KEPORT   OF   CASE,  [MARCH 

able  increase  of  vocal  fremitus  on  the  right  side  at  its  upper  part, 
and  a  diminution  of  the  fremitus  throughout  the  left  side. 

Percussion. — The  note  is  slightly  higher  pitched  in  the  right 
infra-clavicular  region,  but  anteriorly  is  otherwise  normal.  Pos- 
teriorly the  note  on  the  left  side  is  higher  pitched  than  on  the 
right  from  the  middle  of  the  interscapular  region  downwards,  and 
reversely  it  is  higher  pitched  from  that  region  upwards  towards 
the  right  apex. 

Auscultation. — Anteriorly  :  On  the  left  side  the  respiration  is  in- 
distinct. On  the  right  side  inspiration  is  rougher,  and  expiration  is 
prolonged.  There  are  no  accompaniments.  Posteriorly :  On  the 
left  side  the  respiration  is  indistinct  from  the  infra-spinous  region 
to  the  base.  On  the  right  side  inspiration  is  harsh,  expiration  is 
prolonged,  and  there  are  occasional  crepitations  at  the  end  of 
inspiration,  more  especially  in  the  infra-spinous  region.  The 
vocal  resonance  is  more  marked  on  the  right  side,  both  anteriorly 
and  posteriorly. 

The  Circulatory  Si/stem  presented  nothing  abnormal,  excepting 
an  undue  prominence  of  the  veins  on  the  left  side  of  the  neck  and 
upper  part  of  thorax.  There  is  visible  pulsation  at  the  apex  of  the 
heart,  as  also  in  the  epigastrium,  and  at  the  episternal  notch  as 
well  as  in  the  carotids.  The  first  sound  in  the  mitral  area  is  slightly 
impure,  and  the  walls  of  the  bloodvessels  are  somewhat  hard,  but 
otherwise  the  condition  of  the  heart  and  vascular  system  is  normal. 
The  pulse  is  70  per  minute,  and  regular. 

The  liver  is  enlarged.  Its  upper  margin  is  at  the  lower  border 
of  the  fourth  rib,  and  it  extends  downwards  for  7  inches  in  the 
mammary  line.     The  patient  was  now  ordered — 

]^     Potass.  lodidi,         .         .         .  3ij. 

Tr.  Cinchonse  co.,    .         .         .  3iv. 

Infus.  Calumbse  ad.,  §vj.     Misce. 
Sig. — §ss.  ter  in  die  post  cib. 

Nov.  12. — Pain  in  shoulder  better. 

Nov.  16. — The  hardness  in  the  axilla  and  the  fulness  above  the 
left  clavicle  are  diminishing  in  size  and  are  not  so  painful. 

Nov.  23. — Patient  feels  stronger ;  the  enlarged  glands  in  the  neck 
seem  smaller. 

Dec.  1. — Patient  complains  of  severe  pain  in  the  left  shoulder- 
joint. 

Dec.  16. — The  joint  is  less  painful,  but  patient  is  unable  to 
raise  his  arm.  The  glands  are  smaller,  but  there  is  distinct  atrophy 
of  the  left  deltoid  muscle,  and,  to  a  lesser  extent,  wasting  of  the 
other  muscles  of  the  arm.  The  interrupted  current  to  be  applied 
to  shoulder  and  arm. 

Dec.  29. — Patient  discharged  relieved.  Pain  in  the  shoulder 
better ;  glands  smaller,  and  the  atrophy  of  the  muscles  less  marked. 
Movement  in  the  arm  better. 

Jan.  17,  1889. — Patient  seen  in  out-patient  department  of  the 


1889.]  BY    DK   J.    ALLAN    GRAY.  837 

Hospital.  Enlargement  of  axillary  gland  quite  gone,  but  fulness 
in  the  left  supra-clavicular  region  still  present.  Movements  of  the 
arm  quite  natural,  but  atrophy  of  the  deltoid  not  altogether  gone. 
Some  pain  at  the  angle  of  scapula.  The  percussion  note  is  higher 
pitched  over  the  apex  of  the  right  lung,  and  the  breath  sounds  are 
louder  throughout  the  right  lung.     Prescription  changed  to 

^     Pot.  lodidi,        ....         3ij. 
Liq.  Hydrargyri  perchloridi,      .         §iss. 

Aq.  ad., §vj. 

Sig. — §ss.  in  water  thrice  a  day,  and  cod-liver  oil  to  be  taken. 

Feb.  12. — Patient  has  been  at  work  since  date  of  last  note,  and 
expresses  himself  as  being  in  good  health.  The  atrophied  deltoid 
is  now  almost  normal,  and  has  regained  its  former  power.  There 
is  still  a  slight  fulness  above  the  clavicle,  but  the  other  glandular 
enlargements  have  disappeared.  The  left  lung  is  almost  the  same 
as  its  neighbour,  except  for  the  slight  amount  of  old-standing  con- 
densation of  the  right  apex.  Impurity  of  first  sound  in  mitral  area 
greater,  and  so  5  minim  doses  of  tincture  of  digitalis  to  be  added 
to  mixture. 

Remarks  hy  Br  Gray. — One  of  the  most  noticeable  things  in  this 
case  is  the  long  absence  of  any  definite  physical  signs,  and  tlien  their 
sudden  development.  From  the  17th  October,  when  the  patient  came 
under  my  care,  up  to  9th  November,  no  other  diagnosis  than  that  of 
intercostal  neuralgia  and  muscular  rheumatism  of  the  shoulder  was 
warranted  by  the  signs.  But  continued  intercostal  neuralgia,  un- 
attended by  herpes  and  unaccompanied  by  any  spinal  disease,  is  a 
rare  ailment.  I  sought  to  find  its  cause  in  some  local  condition, 
but  failed,  and  so  was  fain  to  attribute  it  to  the  anaemic  state 
of  the  patient,  and  to  some  possible  malarial  taint  caught  abroad. 
On  this  theory  iron  and  arsenic  were  prescribed,  with  cascara 
sagrada  to  counteract  the  constipation  from  which  the  patient 
suffered.  But  this  prescription  had  no  marked  beneficial  effect. 
Throughout  his  residence  in  the  Hospital  the  man  had  been  specially 
sullen  and  taciturn,  and  on  the  occasion  of  the  1st  November  these 
characteristics  were  so  pronounced  as  to  lead  Dr  Graham  (late  of 
Sydney  Hospital),  who  assisted  me  in  examining  him,  to  suggest 
that  the  patient's  mental  condition  would  probably  deserve  notice 
at  a  later  date. 

But  on  the  9th  November  the  appearance  of  the  swollen  gland 
in  the  left  axilla  put  a  new  complexion  on  affairs.  This  appear- 
ance, taken  in  conjunction  with  the  swelling  above  the  clavicle, 
the  thickening  of  the  tissues  at  the  back  of  the  neck,  the  enlarge- 
ment of  the  sterno-mastoid  glands,  and  the  evidences  of  pressure 
on  the  intrathoracic  veins,  and  on  at  least  one  of  the  bronchi  of 
the  left  lung,  made  the  diagnosis  of  a  tumour  of  the  chest  almost 
a  certainty.  Then  if  a  tumour,  of  what  nature  ?  An  aneurism  or 
a  solid  growth  ?  And  if  the  latter,  a  solid  growth  of  what 
character  ?     That  the  intrathoracic  swelling  was  aneurismal  was 


838  CLINICAL   REi'OKT   OF   CASE.  [MARCH 

unlikely,  in  view  of  the  absence  of  the  evidence  of  a  special  affec- 
tion of  the  heart  or  bloodvessels,  aiid  in  view  of  the  presence  of 
glandular  swellings  and  vague  tissue  thickenings.  That  the  tumour, 
if  solid,  was  not  a  lymphadenoma,  might  be  inferred  from  the  con- 
dition of  the  spleen  and  blood.  The  choice,  tlierefore,  lay  between 
a  malignant  tumour  and  a  specific  growth.  Towards  the  former  I 
must  confess  I  was  in  the  first  instance  attracted  by  a  considera- 
tion of  the  rapidity  of  the  illness,  the  sudden  appearance  of  glan- 
dular swellings,  and  the  ansemic,  almost  cachetic  condition  of  the 
patient,  as  well  as  by  the  absence  of  any  history  or  special  evidence 
of  specific  disease.  But  the  possibility  of  the  growth  being  after 
all  of  a  specific  character  was  suggested  to  me,  and  as,  of  course, 
one  must  in  a  doubtful  case  treat  a  patient  according  to  the  more 
hopeful  prognosis,  the  mixture  containing  iodide  of  potash  was 
prescribed.  Further  consideration  likewise  tended  to  support  this 
view ;  for  the  tissue  thickening  at  the  back  of  the  head  was  surely 
not  likely  to  occur  from  any  other  disease,  unless,  indeed,  it  might 
be  attributed  to  sympathetic  swelling.  And  the  intercostal 
neuralgia,  although  readily  enough  explained  by  the  pressure  of  a 
malignant  tumour  growing  from  the  connective  tissue  or  glands  of 
the  mediastinum,  was  better  accounted  for  by  the  hypothesis  of  a 
tertiary  growth  springing  from  the  periosteum  of  the  vertebrae. 
That  this  latter  was  the  ailment  appears  almost  beyond  doubt, 
alike  from  the  facts  of  case  and  the  results  of  treatment. 


I^att  ^econti. 


REVIEWS. 

Diseases  of  the    Urinary   Organs.      By   Sir   Henry   Thompson. 
Eighth  Edition.     London  :  J.  &  A.  Churchill :  1888. 

The  former  edition,  issued  in  a  cheap  form  for  the  benefit  of 
students,  consisted  of  twenty-six  lectures.  This  edition  contains 
thirty-two.  The  new  lectures  are  mainly  on  the  subject  of  opera- 
tions— suprapubic  cystotomy  being  the  principal  one.  We  select 
the  following  points  for  comment. 

Sir  Henry  Thompson  gives  Dr  J.  G.  Garson  full  credit  for 
having  first  pointed  out  how  medium  distension  of  both  rectum 
and  bladder  is  the  best  means  of  keeping  the  peritoneum  out  of 
harm's  way  in  suprapubic  operations.  He  also  reproduces  Dr 
Garson's  admirable  plates.  In  describing  the  operation  for  the 
removal  of  a  calculus,  he  advocates  the  distension  of  the  rectum  by 
Petersen's  bag  as  more  important  than  distension  of  the  bladder. 
He  describes  an  ivory  separator  which  he  employs  in  preference  to 
knife  or  finger,  and  he  says  that  he  prefers  his  fingers  for  the 
extraction  of  the  stone,  hooking  the   forefinger  of  the  one  hand 


1889.]  DISEASES   OF   THE   UKINARY   OEGANS,   ETC.  839 

under  it  and  steadying  the  stone  with  the  other  forefinger ;  that  in 
this  way  tiie  stone  is  easily  extracted,  and  the  opening  in  the  bladder 
not  too  much  stretched  if  care  is  taken.  In  speaking  of  those 
cases  in  which  the  operation  sliould  be  preferred,  he  remarks, 
"  It  is  my  belief  that  in  the  hands  of  most  operating  surgeons  this 
proceeding  will  prove  a  safer  and  a  far  easier  one  than  lithotrity, 
with  all  its  advantages,  for  hard  stones  when  they  have  arrived  at 
the  weight  of  about  one  and  a  half  ounce  or  two  ounces"  (page 
191).  In  another  place  he  says,  "  If  we  can  eliminate  from  the 
suprapubic  operation  its  one  source  of  uncertainty  and  danger 
relating  to  tlie  peritoneum,  we  possess  a  means  incomparably 
superior  to  the  lateral  procedure  for  large  stones,  if  not,  indeed,  for 
any  which  cannot  be  easily  removed  by  lithotrity"  (page  195). 
From  these  statements  we  understand  that,  in  Sir  Henry  Thompson's 
opinion,  an  opinion  which  we  share  doubtless  with  many  others, 
this  operation  is  a  safer  one  than  even  lithotrity,  except  when  the 
latter  is  performed  by  an  experienced  surgeon  or  under  very 
favourable  circumstances. 

Sir  Henry  Tiiompson  tells  us  that  his  lectures  have  been  trans- 
lated into  five  languages.  This  is  only  what  one  would  expect 
considering  the  eminence  of  the  author  and  the  high  merit  of  the 
lectures  themselves.  They  are  printed  as  delivered,  and  have  thus 
the  interest  and  attractiveness  of  viva  voce  demonstrations. 

There  are  121  illustrations,  many  of  them  artistic  as  well  as 
instructive. 

On  the  Preventive  Treatment  of  Calculous  Disease  and  the  Use  oj 
Solvent  Remedies.  By  Sir  Henry  Thompson,  F.E.C.S.,  M.B. 
Lond.     3rd  edit.     London  :  J.  &  A.  Churchill :  1888. 

Every  practitioner  will  welcome  this  edition  of  Sir  Henry 
Thompson's  three  admirable  lectures  on  this  most  important 
subject.  The  first  is  concerned  with  the  "  Early  History  of 
Calculous  Disease  and  the  Treatment  best  Adapted  for  its 
Prevention ; "  the  second  with  the  "  Dietetic  Treatment  of 
Patients  Excreting  Uric  Acid  in  Excess ;  "  while  the  third  is  "  On 
the  Treatment  of  Stone  in  the  Bladder  by  Solvents :  its  History 
and  Practice." 

The  style  is  of  course  delightful,  and  its  excellence  is  only 
surpassed  by  that  of  the  subject  matter.  Without  any  pretension  of 
great  scientific  knowledge,  the  author  treats  his  subject  in  a  most 
thoroughly  scientific  manner.  His  arguments  against  the  simple 
use  of  alkalis  are,  to  our  mind,  most  admirable,  while  the  full 
recognition  of  the  importance  of  the  condition  of  the  alimentary 
canal,  and  the  clear  and  practical  directions  in  regard  to  its  manage- 
ment, are  just  what  is  wanted.  We  most  thoroughly  agree  with 
his  views  in  regard  to  diet.  However  explained,  there  can  be  no 
doubt  that  the  uric  acid  production  in  relationship  to  urea  is  reduced 
on  a  flesh  diet,  and  is  raised  upon  a  diet  rich  in  fats  and  carbo- 


840  holmes'  surgery,  etc.  [march 

hydrates.     This  important  fact  is,  however,  too  often  ignored  in  the 
treatment  of  those  tending  to  form  an  excess  of  uric  acid. 


Holmes'  Surgery.     Fifth  Edition.     Edited  by  T.  Pickering  Pick, 
F.R.C.S.,  etc.     London  :  Smith,  Elder,  &  Co. :  1888. 

This  edition  is  well  got  up,  and  exceeds  the  former  editions  in 
the  number  of  pages  and  illustrations,  even  though  the  chapter  on 
affections  of  the  eye  has  been  omitted.  The  general  scope  of  the 
work  has  been  increased  rather  than  diminished,  and  the  subjects, 
such  as  abdominal  and  cerebral  surgery,  which  more  especially 
attract  surgeons  at  present,  are  dwelt  upon.  The  general  pathology 
is  brought  up  to  date,  and  the  value  of  the  book  as  a  guide  and 
work  of  reference  maintained. 

We  have  much  pleasure,  therefore,  in  recommending  this  edition 
to  students  and  practitioners. 


On  the  Surgery  of  the  Knee- Joint,  and,  the  Responsibility  placed  on 
the  Physician  and  General  Practitioner  hy  the  Modern  Progress  of 
Surgery :  being  the  inaugural  and  retiring  Presidential  Addresses 
delivered  before  the  West  London  Medico- Chirurgical  Society  on 
7th  October  1887  and  Uh  May  1888  respectively.  By  C.  B. 
Kketley,  r.R.C.S.,  Senior  Surgeon  to  the  West  London 
Hospital,  etc.     Pp.  25.     London  :  Bailliere,  Tindall,  &  Cox. 

This  little  book  is  not  a  comprehensive  treatise  upon  the  surgical 
treatment  of  injuries  and  diseases  of  tlie  knee-joint,  as  the  title  "  On 
the  Surgery  of  the  Knee-Joint,"  which  stands  on  the  cover,  would 
lead  us  to  expect,  but  is  merely  a  reprint  of  two  presidential 
addresses,  the  subjects  of  which  are  explained  more  fully  on  the 
title  page.  The  first  one  dwells  upon  the  importance  of  antiseptics 
and  the  advantages  of  erasion  over  routine  excision  in  dealing  with 
tubercular  joints.  Although  the  author  may  be  right  in  saying 
that  ten  years  ago  these  methods  were  not  in  general  use,  still  to 
followers  of  Professor  Lister's  cliniques,  even  the  later  of  them — 
erasion — was  familiar  in  1876.  Undoubtedly,  however,  operations 
and  their  results  have  been  improved  by  modern  progress.  Perhaps 
in  another  ten  years  we  shall  not  want  to  operate  so  much  even 
with  still  more  improved  methods.  We  may  by  that  time  have 
learned  how  to  aid  the  tissues  to  fight  out  and  win  their  own 
battles  with  bacilli  without  the  need  of  sweeping  both  combatants 
off  the  field. 

In  the  second  address  Mr  Keetley  has  raised  a  most  important 
question  in  referring  to  those  cases — formerly  generally  fatal — 
which  ought  to  be  saved  by  surgical  interference  if  only  it  is  in 
time.  Drawing  attention  to  them  is,  however,  all  very  well,  and 
more  could  not  be  expected  in  a  single  address.  The  service 
to  busy  practitioners  would  be  much  greater  if  Mr  Keetley  with 


188!).]  HUNTERIAN   LECTURES,   ETC.  841 

his  wide  experience  would  collect  together  the  most  important  of 
such  cases  and  explain  their  symptoms,  diagnosis,  and  treatment  in 
his  own  vigorous  style. 

Hunterian    Lectures.     By    Thomas    Bryant,    F.R.C.S.,    etc. 
London :  J.  &  A.  Churchill :  1888. 

These  three  lectures  on  Tension^  Infiammation  of  Bone,  and 
Cranial  Injuries  were  delivered  before  the  Royal  College  of 
Surgeons  in  June  1888.  They  contain  a  great  amount  of  plain 
speaking  and  valuable  clinical  information  that  is  not  found  in 
systematic  works  on  surgery.  They  are  a  most  valuable  contribu- 
tion to  practical  surgery,  and  deserve,  especially  the  one  on  cranial 
injuries,  to  be  read  by  every  practitioner. 


Guy's  Hospital  Reports.  Edited  by  N.  Davies-Colley,  M.A.,  M.C., 
and  W.  Hale  White,  M.D.  Vol.  XLV.  London :  J.  &  A. 
Churchill:  1888. 

This  volume  is  a  very  excellent  one,  and  shows  that  the  staff  of 
this  fine  old  Hospital  and  School  are  doing  good  work. 

A  very  sympathetic  and  pleasantly  written  obituary  notice  of 
the  late  Dr  Robert  Edmund  Carrington  precedes  the  more  strictly 
professional  articles.  Of  these  the  most  important  are, — 1.  Sixth 
Report  of  the  Guy's  Hospital  Lying-in  Charity  from  1875  to  1885. 
It  contains  the  records  of  results  in  25,489  cases.  The  maternal 
mortality  is  3-4  per  1000,  or  1  in  296.  2.  Mr  Golding  Bird's  paper 
on  the  Rational  After-treatment  of  Surgical  Cases.  This  contains 
some  excellent  common  sense  observations  on  feeding  after  operation, 
on  the  abuse  of  ice,  and  the  risks  of  cold.  3.  Dr  Hale  White's 
paper  on  Simple  Ulcerative  Colitis  and  other  Rare  Intestinal  Ulcers. 
4.  Statistics  of  Secondary  Haemorrhage  after  Amputation,  with 
Statistics  of  Amputation  at  Guy's  Hospital  for  forty-two  years  by 
John  Poland.  5.  The  Importance  of  Peritoneal  Effusions,  by  R. 
Lawford  Knaggs,  B.C.  Many  other  papers  of  value  and  interest, 
with  lists  of  officials,  students,  prizemen,  and  a  first-rate  index  to 
the  last  ten  volumes — make  up  a  most  capital  record  of  hospital 
life  and  work. 


Fletcher's  New  Patent  Calendar  for  1889  is  an  ingenious  mode  of 
advertising  combined  with  a  calendar.  It  is  on  the  principle  of  a 
Shakespeare  calendar,  with  this  difference,  that  while  in  the  one  you 
get  a  line  from  Shakespeare  along  with  a  page  giving  the  day  of 
the  month  and  of  the  week,  in  this  calendar  you  get  a  picture  of  a 
gas  stove,  or  a  quick  coffee  roaster,  or  an  instantaneous  water  heater, 
or  a  reverberatory  furnace,  or  a  boiler  and  griller,  so  that  you  know 
that  Mr  Fletcher  sells  at  least  365  different  varieties  of  heating 
apparatus. 

EDINBURGH   MED.    JOUEN.,   VOL.    XXXIV. — NO.    IX.  5  0 


842  MEETINGS   OF   SOCIETIES.  [MARCH 


MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY   OF    EDINBURGH. 

SESSION   LXVIII. — MEETING  IV. 

Wednesday,  16th  January  1889. — Prof.  Simpson  in  the  Chair. 

I.  New  Members. 

The  following  gentlemen  were  elected  Ordinary  Members  of  the 
Society :— Charles  H.  Bedford,  M.B.,  M.RC.S.,  F.S.A.,  2  Windsor 
Street,  Edinburgh ;  William  Haldane,  M.D.,  Viewforth,  Bridge  of 
Allan  ;  J.  H.  A.  Laing,  M.B.,  CM.,  11  Melville  Street,  Edinburgh  ; 
Harold  J.  Styles,  M.B.,  University. 

II.  Card  Specimens. 

Dr  Alex.  Bruce  showed — (1),  two  specimens  of  melanotic  sarcoma 
OF  THE  LIVER  occurring  after  removal  of  the  eye-ball  for  melanotic 
disease ;  and  (2),  a  carcinoma  of  the  liver  spreading  along  the 
portal  vein. 

III.  Pathological  Specimens. 

1.  Mr  F.  M.  Caird  showed  a  specimen  in  which  there  was  an 
artificial  anus  on  one  side  with  a  return  of  hernia  on  the  other. 
The  patient  was  admitted  with  a  femoral  hernia  which  had  been 
down  for  some  time.  During  the  operation  the  gut  gave  way.  It 
had  to  be  brought  to  the  surface  and  an  artificial  anus  formed. 
The  peritoneal  cavity  was  washed  out  with  warm  boracic  lotion. 
Death  occurred  in  eight  hours.  At  the  post-mortem  examination 
it  was  noticeable  that  there  was  no  fascal  matter  in  the  abdomen. 
On  the  opposite  side  there  was  a  cicatrix,  the  result  of  an  opera- 
tion for  hernia  by  Dr  Cotterill  six  years  before.  A  new  hernial 
sac  had  formed  and  gone  down  the  old  course. 

2.  Dr  Francis  Troup  showed  two  specimens  of  thoracic 
aneurism.  They  were  chiefly  remarkable  for  their  large  size. 
One  of  the  patients  obtained  great  relief  from  the  use  of  ice,  and 
it  was  remarkable  that,  though  his  skin  was  kept  at  a  low  tempera- 
ture for  a  very  long  time,  no  sloughing  took  place,  and  he  ultimately 
died  of  exhaustion. 

3.  Dr  Philip  showed  membranous  fragments  passed  per  urethram 
by  the  patient  whose  case  he  read  afterwards. 

IV.  Therapeutic  Agent. 

Dr  Philip  showed  an  emulsion  containing  cod-liver  oil  to  the 
extent  of  75  per  cent.,  and  eucalyptus  oil  in  the  proportion  of 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF  EDINBURGH.  843 

twenty  minims  to  the  tablespoonful.  For  about  two  years  he  had 
used  the  pure  oil  of  eucalyptus  internally  with  great  advantage  in 
a  large  number  of  cases  of  phthisis  pulmonum.  Tue  emulsion  was 
the  result  of  many  attempts  made,  at  his  suggestion,  by  Messrs 
Baildon  &  Son,  for  the  purpose  of  combining  the  drug  with  cod- 
liver  oil.  It  had  the  further  advantage  that  the  eucalyptus  oil 
disguised  the  taste  of  the  cod-liver  oil  better  than  any  other  agent 
he  knew, 

V.  Original  Communications. 

1.  Dr  B.  W.  Felkin  read  notes  on  a  case  of  elephantiasis, 
which  appears  at  page  779  of  this  Journal. 

Professor  Simpson  thought  the  members  were  indebted  to  Dr 
Felkin  for  his  valuable  paper.  It  would  be  interesting  to  have  the 
opinion  of  surgeons  or  dermatologists  present  as  to  the  nature  of 
the  case,  which  seemed  in  some  of  its  features  to  be  allied  to 
scleroderma.  He  (Prof.  Simpson)  considered  that  the  influence  of 
the  massage  was  a  point  of  great  importance,  and  asked  if  the 
nausea  created  by  fish  remained  after  the  improvement  in  the 
patient's  health  had  been  established. 

Dr  Dods  asked  if  there  was  any  history  of  erysipelas,  repeated 
attacks  of  which  were  declared  by  some  observers  to  be  a  cause  of 
elephantiasis.  He  had  seen  a  large  number  of  cases  of  this  affec- 
tion, but  none  like  what  Dr  Felkin  had  described.  He  never 
saw  a  case  in  which  the  ankles  were  not  affected.  The 
swellings  usually  began  in  the  most  dependent  parts,  which 
might  be  expected,  as  elephantiasis  is  evidently  a  disease  of  the 
cellular  tissue.  He  had  seen  one  case  in  which  the  redundancy  of 
cellular  tissue  had  formed  two  large  tumours  on  the  back  of  the 
thighs, — one  of  these  when  removed  measured  42  inches  in  circum- 
ference and  weighed  15  lbs.  It  consisted  of  cellular  tissue,  dense 
at  the  circumference,  and  soft  in  the  centre,  with  fluid  in  the  large 
meshes  of  the  tissue.  In  another  case  of  elephantiasis  of  the  face, 
the  patient's  profile  resembled  that  of  a  horse.  He  never  knew  of 
any  cases  of  true  elephantiasis  being  benefited  by  treatment.  There 
was  often  an  improvement  if  the  patient  were  removed  from  the 
region  where  the  disease  is  supposed  to  prevail,  viz.,  the  vicinity  of 
the  sea. 

Br  Haddon  wished  to  know  whether  the  improvement  in  the 
case  was  due  to  the  treatment  that  had  been  adopted  or  to  the 
change  undergone  in  coming  to  this  country.  He  thought  the 
number  of  remedies  used  at  the  same  time  made  it  rather  difficult  to 
draw  conclusions  as  to  the  cause  of  the  improvement. 

Mr  Cathcart  asked  if  massage  had  been  used  in  the  treatment 
of  other  cases  of  the  disease. 

Dr  Felkin  said  that  he  was  familiar  with  the  scrotal  tumours  to 
which  Dr  Dods  referred,  and  once  removed  one  which  weighed  98 
pounds.     He  had  also  seen  cases  of  lymphoid  elephantiasis,  but  the 


844  MEETINGS   OF   SOCIETIES.  [MARCH 

present  case  was  not  one  of  that  description.  At  first  he  thought 
it  might  be  so,  but  although  punctures  were  made  in  various  parts 
no  fluid  whatever  could  be  obtained.  Massage  was  not  recognised 
as  routine  treatment  in  these  cases.  He  did  not  think  that  the 
tonics  and  battery  either  complicated  the  treatment  or  were 
unscientific.  The  methods  employed  had  a  definite  object  in  view, 
which  object  was  attained  to  a  higher  degree  than  hoped  for.  In 
this  case  the  change  of  climate  had  no  beneficial  effect ;  althougli 
unaccompanied  by  pain  or  fever,  the  hypertrophy  continued  both 
during  the  voyage  to  England  and  after  arrival  there,  the  patient 
increasing  some  two  stones  in  weight  after  leaving  India.  With 
regard  to  the  possibility  of  the  production  of  elephantiasis  only  on 
the  sea  coast  or  as  far  as  the  cocoa-nut  grows,  Dr  Felkin  did  not 
believe  the  theory,  as  he  had  seen  so  many  cases  of  the  disease  in 
Central  Africa. 

2.  Professor  Annandale   read   his   paper   on   the  eemoval  by 

OPERATION   OF    NASO-PHARYNGEAL    TUMOURS.      He    Stated    that    his 

principal  object  in  reading  this  paper  was  to  describe  a  method  of 
operating  carried  out  successfully  in  three  cases  recently  under  his 
care.  He  had  studied  the  many  and  various  methods  previously 
suggested  and  practised  for  the  removal  of  these  growths,  and 
although  his  own  method  was  not  original  in  some  of  the  details, 
he  believed  that  in  its  entirety  the  procedure  was  new.  Having 
freely  admitted  that  some  growths  in  this  region  might  be  removed 
by  other  than  a  cutting  operation,  he  described  the  steps  of  his 
procedure  as  follows  : — (1.)  The  exposure  of  the  anterior  nares  by 
freely  dividing  the  mucous  membrane  connecting  the  upper  lip 
and  upper  jaws  according  to  the  plan  of  Eougd  (2.)  The  division 
of  the  bony  septum  of  the  nose  along  its  attachment  to  the  jaw. 
(3.)  Incising  the  soft  parts  along  the  middle  line  of  the  hard  palate, 
and  then  sawing  through  the  alveolar  margin  of  the  upper  jaw, 
and  through  the  entire  hard  palate  along  the  same  line.  The  soft 
palate  may  or  may  not  require  division  in  its  middle  line.  (4.) 
The  forcible  separation  of  the  two  jaws,  and  the  introduction, 
through  the  gap  of  the  finger,  of  the  periosteal  scraper  or  other 
similar  instrument,  with  a  view  of  separating  the  secondary  con- 
nexions of  the  growth  to  surrounding  parts.  (5.)  The  removal  of 
the  growth  from  its  primary  site  of  origin  by  forceps,  sharp  spoon, 
cold  snare,  or  galvanic  wire.  After  the  operation  the  two  jaws  are 
brought  together,  and  retained  by  one  or  more  sutures.  Professor 
Annandale  believed  that  his  operation  had  for  the  first  time 
demonstrated  the  fact,  that  the  upper  jaws,  after  such  a  section, 
could  be  separated  to  an  extent  so  as  to  give  access  to  the  base  of 
the  skull  and  posterior  nares.  Three  cases  recently  operated  upon 
with  success  were  then  reported  in  detail. 

Professor  Simpson   said  he  had  seen   Middeldorpf  of  Breslau 
operate  a  great  many  years  ago  on  a  tumour,  such  as  those  described 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  8-45 

by  Professor  Annandale,  by  means  of  galvano-caustic  wire.  Mr 
Annandale's  paper  was  of  unusual  value  because  of  the  original 
procedure  he  had  devised  for  getting  access  to  the  root  of  the 
disease.  It  was  new  to  him  that  so  much  space  could  be  gained 
by  splitting  in  the  centre  the  palatal  portions  of  the  superior 
maxillae.  It  was  not  easy  at  once  to  see  how  this  came  about,  and 
he  considered  that  a  supplemental  anatomical  research  would  add 
to  the  value  of  Professor  Annandale's  important  communication. 

Mr  Cathcart  thought  the  amount  of  space  gained  depended  on 
the  age  of  the  patient.  With  a  full-grown  hard  skull,  it  would  be 
very  difficult  to  wrench  aside  the  cut  parts  to  such  an  extent,  but 
with  a  young  skull  he  thought  it  would  be  easy.  A  greenstick 
fracture,  bending  the  wings  of  the  sphenoid  and  the  zygomatic 
arch,  probably  occurred.  One  advantage  over  the  galvano-caustic 
wire  of  this  operation  was  that  they  could  be  pretty  certain  of 
getting  away  the  whole  of  the  growth.  He  did  not,  however,  know 
whether  recurrence  had  been  observed  after  the  use  of  the  wire. 
He  asked  Mr  Annandale  if  he  did  not  think  he  could  accomplish 
all  he  desired  by  incising  the  soft  palate  alone.  If  he  could  do  so, 
it  would  be  a  great  gain. 

Dr  M'Kcnzie  Johnston  said  he  had  not  noticed  any  reference  in 
Mr  Annandale's  paper  to  the  dangers  of  this  operation.  He  should, 
therefore,  like  to  ask  him  whether  it  was  not  such  a  serious  one 
that  it  should  only  be  tried  after  the  failure  of  all  milder  measures, 
and  after  setting  fully  before  the  patient  its  risk  ?  The  three 
successful  cases  recorded  by  Mr  Annandale  were,  no  doubt,  due  to 
his  skill  as  an  operator,  but  in  a  series  of  similar  operations 
recorded  there  were  eight  deaths  in  twenty-four  cases,  showing  the 
formidable  nature  of  the  operation.  By  hooking  forward  the  soft 
palate  under  cocaine,  it  was  surprising  the  amount  of  apace  that 
could  be  obtained  for  operative  procedure,  and  he  thought  no  case 
should  be  submitted  to  the  cutting  operation  till  it  had  been 
proved  impossible  to  remove  the  growth  otherwise. 

Mo'  Annandale  said  Esmarch  and  the  American  surgeons  who 
witnessed  his  second  operation  were  astonished  at  the  amount  of 
space  gained.  After  he  tried  it  in  his  first  case,  he  asked  Sir 
William  Turner  if  it  could  be  done  in  the  dead  body,  and  was  told 
it  could  not.  Division  of  the  soft  palate  had  been  tried,  and  had 
failed  to  give  the  necessary  access.  His  best  answer  to  Dr 
M'Kenzie  Johnston  was  the  fact  that  his  third  case  had  been  sent 
to  him  by  Dr  M'Bride  for  operation.  He  believed  that  in  the 
majority  of  these  cases  a  cutting  operation  would  be  found 
necessary. 

3.  Br  Philip  read  his  paper  ON  TUBERCULOSIS  OF  the  bladder 

IN  A  CASE  OF  phthisis  PULMONALIS. 

Professor  Simpson  said  that  in  the  female  one  might  not  unfre- 
quently  see  the  correlation  of  tuberculosis  of  the  genito-urinary 


846  MEETINGS   OF   SOCIETIES.  [MARCH 

system  and  lung  disease,  but  there  had  always  been  marked 
dysuria  in  all  the  cases  that  had  come  under  his  observation.  He 
never  saw  a  case  with  such  an  absence  of  symptoms  as  described 
by  Dr  Pliilip. 

Professor  Annandale  was  glad  that  Dr  Philip  had  described  this 
case  of  tubercular  disease  of  the  bladder  so  carefully,  because  it 
was  a  subject  about  which  the  books  said  very  little.  He  could 
recall  four  or  five  cases  in  which  after  opening  the  bladder  for 
chronic  cystitis,  he  had  come  upon  ulcerations  of  a  similar  character 
which  he  had  believed  to  be  tubercular. 

Dr  James  Ritchie  was  struck  by  the  absence  of  symptoms,  and 
asked  what  was  the  condition  of  the  young  man's  nervous  system. 
Was  he  one  who  bore  pain  readily  ? 

Mr  Cathcart  thought  the  absence  of  cystitis  partly  explained 
the  absence  of  pain,  but  the  position  of  the  ulcer  was  also  impor- 
tant. When  the  ulceration  affected  the  base  of  the  bladder  or 
extended  around  its  neck  the  symptoms  were  distinct,  but  high 
up  the  symptoms  were  mild  or  absent  altogether.  In  Dr  Philip's 
case  the  larger  ulcer  lay  on  the  front  of  the  bladder  above  the 
urethral  orifice,  and  the  smaller  was  near  to  the  orifice  of  one  of 
the  ureters.  This,  however,  was  a  matter  requiring  further 
investigation. 

Dr  Aitken  considered  that  the  condition  of  the  ulcer  itself  might 
account  for  the  absence  of  symptoms,  if  covered  with  pultaceous 
material. 

Dr  Philip  agreed  with  Mr  Annandale  as  to  the  paucity  of 
reference  in  literature  to  tubercular  ulceration  of  the  bladder. 
This  had  been  one  of  his  reasons  for  recording  the  case.  He 
thought  that  cases  such  as  those  Mr  Annandale  mentioned  should 
have  the  urine  examined  for  the  tubercle  bacillus.  He  presumed 
that  if  evidence  was  obtained  of  a  tubercular  lesion  in  the  bladder, 
Mr  Annandale  would  not  operate. 

Professor  Annandale. — But  I  would  certainly  operate. 

Dr  Philip,  continuing,  said  perhaps  in  the  circumstances  the 
patient  would  not  care  to  have  the  operation  performed.  In  any 
case,  it  was  desirable  to  obtain  an  absolute  diagnosis.  In  respect 
of  the  absence  of  urinary  symptoms  he  thought  the  case  peculiar. 
This  was  one  of  the  special  points  which  the  paper  illustrated. 
As  to  the  cause  of  this  absence,  Mr  Cathcart's  view  seemed  to  him 
of  value.  It  was  particularly  to  be  noted  that  apart  from  the 
large  and  small  ulcer  the  vesical  mucous  membrane  was  intact 
and  perfectly  smooth. 


ROYAL  MEDICAL  SOCIETY. 


Jan.  25. — A.  L.  Gillespie,  M.B.,  in  the  Chair.  H.  H.  Littlejohn, 
M.B.J  showed — (1.)  A  specimen  of  Brain  Tumour — a  glioma 
situated  in  the  tip  of  the  left  temporo-sphenoidal  lobe.     (2.)  A 


1889.]  ROYAL  MEDICAL   SOCIETY.  847 

specimen  of  Hasmorrhagic  Pericarditis,  probably  of  septic  origin. 
A  peculiar  feature  in  the  case  was  that,  on  post-mortem  examina- 
tion, the  heart  was  found  in  an  advanced  stage  of  decomposition ; 
the  other  viscera  were  fresh.  (3.)  A  Dissecting  Aneurism  of  the 
Aorta.  (4)  An  Aneurism  of  the  Aortic  Arch,  which  burst  into  the 
pericardium.  F.  D.  Boyd^  M.B.y  showed  a  specimen  of  Incomplete 
Abortion,  the  ovum  being  retained  in  the  cervix.  The  patient 
succumbed  to  pneumonia  of  an  adynamic  type,  and  probably 
septic  origin,  without  the  condition  being  recognised  or  suspected. 
A.  L.  Gillespie,  M.B.,  showed  a  specimen  of  Stricture  of  the  Kectum 
high  up.  There  was  a  perforation,  but  no  marked  thickening  of 
the  wall  of  the  gut.  S.  W.  Carruthers  read  a  dissertation  on 
Aphasia. 

Feb.  1.— R  Abernethy,  M.B.,  in  the  Chair.  fV.  G.  TV.  Sanders 
showed  for  H.  H.  Littlejohn,  M.B.— (1.)  Cirrhotic  Kidneys.  (2.) 
Cystic  Kidneys,  one  containing  large,  the  other  multiple  small 
cysts.  (3.)  An  Ante-mortem  Clot  from  the  pulmonary  vein, 
and  continuous  into  its  smaller  ramifications,  from  a  case  of  head 
injury,  ending  in  coma  of  two  days'  duration.  (4.)  Carcinoma 
of  the  Stomach,  from  a  woman,  aged  62,  who  had  been  ill  two  years, 
and  confined  to  bed  for  fifteen  weeks.  Secondary  growths  had 
occurred  over  the  whole  peritoneum,  giving  rise  to  a  condition  of 
miliary  carcinosis  closely  resembling  tuberculosis.  The  stomach 
exhibited  "  hour-glass "  contraction.  B.  0.  Adamson  communi- 
cated two  cases  of  Burn  over  the  Knee-joint,  of  particular  interest 
from  the  method  of  causation.  In  each  case  the  patient  was  an 
elderly  man  with  marked  arterial  degeneration,  but  previously  in 
apparent  good  health.  Patients  had  fallen  asleep  in  front  of  a 
strong  fire,  with  the  lower  limbs  flexed  at  the  knee,  and  with  their 
clothes  on.  On  waking  up  each  had  sustained  a  severe  burn  over 
the  knee-joint,  although  the  trousers  and  drawers  worn  at  the  time 
were  in  no  way  injured.  In  the  one  case  suppurative  arthritis 
developed,  and  in  spite  of  amputation  patient  sank  and  died.  In 
the  other  a  good  recovery  was  made.  J.  R.  Ratcliffe,  M.B.,  read  a 
communication  on  Testing  of  Air  for  Organisms,  showed  the  ap- 
paratus, and  demonstrated  the  method  of  employing  it.  Specimens 
of  organisms  growing  in  flasks  and  on  gelatine  films  were  also 
displayed. 

Feb.  8. — E.  C.  Carter,  M.B.,  in  the  Chair.  Br  Baton  gave  a 
communication  on  Some  Eecent  Researches  in  Absorption  from 
the  Intestinal  Canal.  H.  H.  Littlejohn,  M.B.,  showed — (1.)  Lung, 
Spleen,  and  Kidney  with  infarcts.  (2.)  Specimens  of  Cystic  Disease 
of  the  Ovaries.  (3.)  Kidney  with  Pyoneplirosis.  (4.)  Surgical 
Kidney.  (5.)  Cast  of  Rupture  of  Biceps  Muscle.  B.  D.  Rudolph 
read  a  dissertation  on  Bruits  of  Debility. 

Feb.  15.— H.  H.  Littlejohn,  M.B.,  in  the  Chair.  H.  H.  Little- 
john^ M.B.,  showed — (1.)  A  Stomach  with  several  Ulcers  on  the 
lesser  curvature,  some  in  a  healing  condition.     (2.)  A  specimen  of 


848  MEETINGS   OF   SOCIETIES.  [mAKCII 

Idiopathic  Purulent  Pericarditis,  from  a  child  who,  till  within  two 
days  of  death,  appeared  in  good  health.  R.  E.  Horsley,  M.B.,  gave 
a  communication  on  Eight  Cases  of  Rupture  of  the  Tympanum 
from  external  violence.  In  all  a  history  of  previous  catarrh  of 
the  Eustachian  tube,  more  or  less  distinct,  was  elicited.  A.  W. 
Carter  communicated,  from  R.  E.  B.  Yelf,  M.B.,  a  case  of  Scalded 
Throat  in  a  child,  in  which  a  successful  result  was  obtained  from 
tracheotomy.  O.  C.  Gathcart  read  a  dissertation  on  Burial 
Reform. 


IJatt  jToutt^, 


PERISCOPE. 

OCCASIONAL  PERISCOPE  OF  DERMATOLOGY. 

By  W.  Allan  Jamieson,  M.D.,  F.R.C.P.,  Extra  Physician  for  Diseases  of 
the  Skin,  Edinburgh  Royal  Infirmary ;  Lecturer  on  Diseases  of  the  Skin, 
Edinburgh  School  of  Medicine. 

Alopecia  Areata. — Two  interesting  papers  on  this  disease  have 
recently  appeared.  One  is  by  Dr  A.  R.  Robinson  {Monatshefte 
filr  praktische  Dermatologie,  1888).  After  discussing  the  arguments 
which  liave  been  brought  forward  by  the  supporters  of  the  neurotic 
and  parasitic  theories  of  its  causation  respectively,  he  concludes, 
from  the  examination  of  portions  of  skin  removed  from  seven  cases 
which  presented  the  disease  in  various  stages,  as  follows : — "  The 
results  of  my  investigations  indicate  that  alopecia  areata  is  to  be 
regarded  as  a  parasitic  affection  of  the  lymph  structures,  and  not 
as  a  disorder  starting  primarily  from  the  hair  or  its  follicle.  That 
the  organisms  are  micrococci,  which  are  located  specially  in  the 
lymph  canals.  That  these  organisms  occasion  inflammatory  changes 
with  considerable  fibrin  coagulation  in  the  lymph  and  bloodvessels. 
That  the  depression  of  the  bald  patches  in  recent  cases  is  due  to 
loss  of  hair  and  diminished  blood-supply  in  the  affected  parts,  to 
which,  in  cases  of  long  duration,  is  added  the  destruction  of  the 
sebaceous  glands  and  atrophy  of  the  corium  and  epidermis.  And, 
finally,  that  the  treatment  by  parasiticides,  in  the  fullest  sense  of 
the  term,  is  the  only  method  in  this  complaint,  and,  in  particular 
in  recent  cases,  which  can  be  regarded  as  certainly  efficient."  Like 
Wilson,  he  extols  croton  oil,  and  says  "  the  favourable  results  which 
were  obtained  by  its  means  depend  on  the  inflammation  thereby 
set  up,  in  process  of  which  the  white  blood  corpuscles  emigrate 
into  the  lymph  channels  in  which  the  organisms  are  present,  and 
there  exhibit  their  antiparasitic  properties  (phagocytes?),  and  so 
remove  the  disease  by  destroying  the  organisms  which  occasion  it." 
He  also  speaks  favourably  of  chrysarobin  in  the  strength  of  15  to 
20  grains  to  the  ounce.     The  other  contribution  is  one  by  M. 


1889.]  PERISCOPE   OF  DERMATOLOGY.  849 

Ernest  Besnier  {Travail  lu  a  VAcadhiie  de  Medccine  dans  sa 
seance  die  31  Juillet  1888).  This  deals  more  with  the  questions 
of  the  transraissibility,  mode  of  propagation,  and  prophylaxis.  As 
regards  the  state  of  the  skin  from  an  affected  part,  the  appearances 
indicate  the  suspension  rather  than  the  suppression  of  hair  growth, 
while  the  hairs  themselves  have  lost  more  or  less  completely  their 
medulla.  Besnier  affirms  that  the  latent  vitality  of  the  hair  may 
persist  for  years,  and  cites  a  case  where  it  was  perfectly  restored 
after  the  baldness  had  been  complete  for  five  years.  If  the  agent, 
still  unknown,  which  causes  it  is  parasitic,  it  is  not  a  parasite  of 
the  hair  proper,  the  condition  is  one  distinct  from  tinea  tonsurans 
or  favus  ;  yet  alopecia  areata  in  its  general  characters  is  much  more 
nearly  allied  to  those  than  to  the  true  trophoneuroses.  He  insists 
on  the  transmissibility  of  the  complaint,  but  this  partakes  also  of 
all  the  irregularities,  inequalities,  contradictions,  and  obscurities 
which  occur  everywhere  in  its  history.  Tlie  most  cursory  observa- 
tion shows  that  the  greater  number  of  those  affected  with  alopecia 
areata  who  do  not  communicate  it  directly  to  others,  are  such  as  have 
naturally  an  oily  scalp  which  is  washed  regularly  every  day  and 
is  suitably  treated.  Contagion  is  much  more  frequently  indirect, 
and  he  believes  this  is  conveyed  by  articles  of  toilet,  by  the  imple- 
ments of  the  hairdresser,  by  interchange  of  head-coverings,  by 
resting  on  pillows,  bolsters,  or  cushions,  when  leaning  the  head 
in  public  conveyances,  or  at  the  barber  or  dentist.  The  inter- 
mediate part  played  by  the  articles  last  named  is  borne  out  by  the 
fact  that  in  the  majority  of  those  attacked  the  posterior  portions 
of  the  cranium  or  nape  of  the  neck  are  the  localities  chiefly  affected. 
Some  cases  are  cited  serving  to  show  that  the  disease  may  possibly 
be  contracted  from  the  lower  animals.  He  further  believes  that 
the  power  of  communicating  it  may  continue  though  the  disease 
is  apparently  at  an  end,  and  can  be  no  longer  discovered  in  those 
believed  to  be  cured,  even  after  careful  examination.  As  to  school 
attendance,  he  would  admit  the  affected  under  strict  rules  as  to 
cleanliness,  keeping  the  head  covered,  and  persistent  treatment. 

Dermatitis  Tuberosa  of  Iodic  Origin. — Dr  R.  W.  Taylor  is 
of  opinion  that  iodic  eruptions  are  most  correctly  and  simply  divided 
into  two  classes — the  heemorrhagic  and  the  dermal  inflammatory. 
When  bullse  are  produced,  such  are  due  to  tissue  peculiarities,  the 
outcome  of  the  inflammation  ;  and  subsequent  warty,  vegetating,  or 
fungating  surfaces  are  due  to  its  intensity  and  persistence.  After 
relating  the  cases  observed  by  Besnier  and  Duhring,  he  details  and 
figures  a  third  observed  by  himself.  This  was  in  a  man  of  26, 
who,  three  years  before,  had  had  a  chancre  followed  by  secondary 
manifestations.  In  consequence  of  severe  nocturnal  pain  in  the 
head,  accompanied  by  remittent  febrile  symptoms  and  splenic 
enlargement,  iodide  of  potassium  was  administered  at  first  in  doses 
of  twenty   grains   thrice  a  day,  but  increased  to   eighty.      The 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    IX.  5   P 


850  PERISCOPE,  [march 

eruption  began  when  forty-grain  doses  were  being  taken.  Tumours 
developed  on  the  forehead,  temple,  right  cheek,  and  left  side  of  the 
face  and  neck.  The  colour  was  deep  red,  and  they  varied  from  a 
threepenny  piece  to  a  shilling  in  size.  They  were  both  peduncu- 
lated and  sessile,  were  covered  with  minute  deep  yellow  crusts, 
and  cribriform  openings  on  their  surface  led  to  small  abscess 
cavities  within.  After  the  discontinuance  of  the  drug  they  withered 
rapidly  when  painted  daily  with  a  solution  of  perchloride  of  iron, 
though  at  the  end  of  a  montli  pigmented  patches,  with  some  degree  of 
atrophy,  remained.  Two  somewliat  similar  examples  were  described 
by  Dr  Hyde  at  the  meeting  of  the  American  Dermatological  Associa- 
tion. In  none  of  the  cases  was  there  any  very  marked  disturbance 
of  the  general  health  from  the  ingestion  of  the  drug. — Neio  York 
Medical  Journal,  3rd  Nov.  1888. 

Some  Dermatological  Don'ts. — Tiie  historic  don't  of  Punch 
has  a  numerous  progeny,  and  a  long  array  formulated  by  Dr  G. 
T.  Jackson  constitute  the  youngest  members.  Some  are  worthy 
of  a  place  here.  Don't  make  your  diagnosis  from  the  history  of  a 
case,  because  if  you  do  you  will  be  often  led  astray.  Make  it 
from  the  eruption  that  you  see,  and  then  substantiate  or  destroy 
this  by  the  history  of  the  case  if  you  will.  Don't  tell  your  patient 
that  it  is  dangerous  to  cure  his  skin  disease  rapidly,  because  it  is 
not.  If  you  don't  know  how  to  treat  the  case,  ask  advice  of  some- 
one who  does.  Don't  give  arsenic  for  every  skin  disease,  and 
especially  don't  give  it  in  acute  eruptions.  Its  sphere  is  in  the 
chronic  scaly  eruptions,  such  as  chronic  psoriasis.  Don't  forget 
that  the  greatest  secret  in  the  treatment  of  eczema,  and  many  other 
skin  diseases,  is  not  what  particular  drug  or  formula  is  "good  for" 
the  disease,  but  a  knowledge  of  the  great  principle  that  acute 
diseases  need  soothing  remedies,  and  subacute  and  chronic  diseases 
need  stimulation.  Don't  expect  to  cure  an  inveterate  eczema  with 
thickened  skin  by  means  of  a  soothing  ointment,  such  as  that  of 
the  oxide  of  zinc,  because  you  will  only  waste  your  time  and  the 
patient's  money.  Don't  apply  a  sulphur  preparation  after  using  a 
mercurial  upon  the  face,  or  vice  versd,  because  if  you  do  you  will 
raise  a  fine  crop  of  comedones. — JVeio  Yorh  Medical  Record,  29th 
December  1888. 


PERISCOPE  OF  GYNECOLOGY  AND  MIDWIFERY. 

By  J.  Milne  Chapman,  M,D,,  Inverness, 

Concerning  a  Certain  Kind  of  Eetention  of  the  Placenta 
(Lange,  Zeitsch.  f.  Geb.  let.,  xv,  1), — The  writer  describes  a  certain 
form  of  retention  of  the  placenta  which  he  has  been  unable  to  find 
described  in  any  of  the  works  on  this  subject.  Being  called  in  by 
a  midwife  in  a  case  of  retained  placenta,  he  found  a  muscular  but 
not  fat  woman  with  thin  abdominal  walls,  and  the  uterus  pro- 


1889.]  PERISCOPE  OF  GYNAECOLOGY  AND  MIDWIFERY.  851 

minent  between  the  separated  recti  muscles,  the  anterior  abdominal 
wfill  being  much  sunken  above  and  at  the  sides  of  the  uterus.  All 
efforts  at  expression  of  the  placenta  by  Credo's  method  proved 
futile.  On  introducing  the  hand,  the  foetal  side  of  the  placenta  was 
felt  just  inside  the  os.  On  reaching  its  margin  with  the  fingers,  it 
came  away  with  a  rush,  but  was  not  followed  by  the  usual  retro- 
placental  flood.  A  second  and  similar  case  occurred  a  year  later. 
The  author  considers  tiie  retention  due  to  the  fact  that  the  ab- 
dominal walls  being  sunken,  the  voluntary  efforts  of  the  patient, 
by  causing  a  contraction  of  the  abdominal  muscles,  produced  a 
separation  of  the  anterior  from  the  posterior  abdominal  wall,  thus 
lowering  instead  of  raising  the  intra-abdominal  pressure. 

Expectant  Method  or  Crede  Manipulation  (Ahlfeld,  Leipsic, 
1888,  Amcr.  Jour,  of  Ohst.,  November  1888). — The  author  reviews 
the  history  of  the  question  which  has  agitated  the  minds  of  prac- 
titioners for  some  time,  and  with  which  the  readers  are  probably 
familiar.  He  then  enters  on  the  considerations  of  the  normal  mode 
of  detachment  of  the  placenta.  Sclmltze  (Jena)  in  1865  gave  an 
approximately  correct  description  of  the  process.  Lemser's  explana- 
tion, published  in  the  same  year,  which  was  based  on  observations 
on  animals,  was  worthless  for  the  human  organism.  Schultze's 
explanation  is  briefly  the  following :  As  soon  as  the  last  portion  of 
the  child  leaves  the  uterus,  the  latter  contracts  so  much  that  the 
placenta,  heretofore  adherent,  must  become  detached.  It  would 
occur  earlier  were  it  not  for  some  of  the  retained  liquor  amnii. 
Normally  the  centre  is  first  loosened,  the  marginal  portion  remain- 
ing adherent.  Detachment  can  occur  only  by  a  pouching  of  the 
centre,  which  leaves  a  cavity  between  the  uterine  wall  and  the 
detached  portion,  which  necessarily  fills  by  aspiration  with  blood 
from,  the  decidual  vessels — the  retro-placental  ligematoma.  The 
first  after-pain  completes  the  detachment.  The  pouching  becomes 
larger,  the  retro-placental  haematoma  increases,  and  the  placenta 
passes  into  the  dilated  cervix.  As  the  marginal  part  is  loosened 
the  membranes  experience  the  traction,  and  their  detachment  is 
inaugurated,  the  retro-placental  hsematoma  crowds  between  the 
lamellae  of  the  decidua,  and  thus  most  gently  separates  the  mem- 
branes. This  detachment  occurs  in  the  dilated  glandular  layer  of 
the  decidua,  the  dense  layer  remains  adherent  to  the  chorion  and 
villi,  and  is  expelled  with  the  after-birth.  If  the  dense  layer  re- 
mains behind,  the  course  is  abnormal,  blood  continues  to  flow  into  the 
sinuses  opened  by  detachment  of  the  villi,  escaping  into  the  cavity  of 
the  uterus  and  outward. 

Duncan,  Crede,  and  Fehling  questioned  whether  this  process  was 
the  normal  one,  and  pleaded  for  another  mode  of  separation 
(Duncan's),  but  hoih  the  Dublin  and  the  Cred^  manipulation  cause 
the  latter  mode  of  separation  by  keeping  the  uterus  in  contraction. 

Crede,  Fehling,  and   others   have   asserted  that  no  proof  has 


852  PERISCOPE.  [march 

been  furnished  of  the  regular  occurrence  of  Schultze's  mode  of 
separation,  but  this  is  not  so,  A  number  of  observers  have  felt 
the  central  bulging  of  the  placenta  on  inserting  their  hand  into 
the  uterus  immediately  after  the  expulsion  of  the  child.  The 
same  phenomenon  has  been  seen  on  opening  the  uterus.  Besides, 
the  sliape  of  the  uterus  containing  the  placenta  speaks  against 
Duncan's  modus :  it  would  have  to  represent  a  narrow  ovoid, 
while  it  usually  assumes  an  almost  globular  form. 

With  the  successive  pains  the  placenta  descends  lower  and  lower. 
Tliis  is  effected  by  the  pressure  of  the  contracting  uterus  on  the  retro- 
placental  hcematoma  more  rarely  by  straining.  By  this  descent 
the  still  adherent  membranes  are  gently  drawn  down,  and  thus 
detached.  In  about  half  an  hour  the  placenta  has  reached  its 
lowest  point  behind  tlie  introitus  vaginae;  there  it  usually  remains, 
and  is  not  expelled  spontaneously.  A  well-preserved  perineum 
especially  contributes  to  this  retention,  and  the  dorsal  position 
favours  it.  If  the  perineum  be  retracted  with  the  finger  or  speculum, 
or  if  the  woman  bear  down,  the  placenta  emerges  from  the  vulva. 
Tlie  membranes  follow  the  placenta  in  the  shape  of  a  long  cord. 
If  the  placenta  be  forced  out  too  early  while  the  membranes  are 
still  retained  above  the  ring  of  contraction  they  are  apt  to  tear. 

The  rarer  (Duncan's)  mode  of  separation  of  the  after-birth. — In 
about  20  per  cent,  of  the  cases  the  lower  margin  of  the  placenta  first 
insinuates  itself  into  the  os.  A  central  detachment  occurs  imperfectly, 
if  at  all.  The  blood  from  the  portions  of  the  maternal  decidua 
where  the  villi  have  separated  flows  unhindered  outward.  If  the 
next  pain  separates  the  placenta  completely,  so  that  the  uterine 
muscle  can  contract  well,  the  haemorrhage  stops.  But  often  the 
placenta  adheres  more  firmly,  and  hence  this  m.odus  is  associated 
with  greater  loss  of  blood.  The  membranes  in  this  modus  are 
detached  solely  by  the  traction  of  the  placenta,  the  preservative 
effect  of  the  htematoma  being  absent,  and  therefore  they  are  more 
liable  to  be  torn  and  retained,  the  uterus  contracts  less  vigorously, 
and  after-haemorrhages  are  the  rule.  This  modus  may  be  produced 
artificially,  if  the  formation  of  the  retro-placental  hasmatoma  is  pre- 
vented by  massage  of  the  uterus  immediately  after  the  expulsion  of 
the  child,  as  by  the  Dublin  or  the  Cred6  manipulation. 

After  considering  the  loss  of  blood  succeeding  the  birth  of  the  child, 
the  importance  of  the  physiological  processes  for  the  course  of  the  third 
stage  of  labour,  the  disadvantages  of  a  too  rapid  and  forcible  separa- 
tion and  expulsion  of  the  after-birth,  Ahlfeld  explains  the  advantages 
of  the  expectant  method  with  reference  to  the  diminished  loss  of 
blood,  the  rarity  of  hasmorrhage  in  the  puerperium  or  of  the  reten- 
tion of  remnants  of  membranes,  and  gives  the  following  directions 
how  the  expectant  method  is  to  be  carried  out.  After  the  delivery 
of  the  trunk,  escape  of  the  retained  liquor  amnii,  and  division  of 
the  cord,  the  external  genitals  are  cleansed  with  cotton  and  sub- 
limate or  carbolic  solution,  and  the  funis  is  laid  over  one  of  the 


1889.]  PERISCOPE   OF   GYNECOLOGY   AND   MIDWIFERY.  853 

flexures  of  the  tliigli.  The  perineum  and  vulva  are  inspected,  and 
bleeding  wounds  are  closed ;  non-bleeding  wounds  are  attended  to 
only  some  time  after  the  termination  of  the  third  stage.  The  wet 
cloths  are  removed,  and  replaced  by  fresh  and  dry  ones,  the  legs 
are  slightly  approximated,  and  the  patient  well  covered.  At  in- 
tervals of  five  minutes  the  covering  is  lifted  and  the  cloths  inspected. 
If  clean,  they  are  left  undisturbed ;  if  a  little  blood  has  escaped, 
the  nurse  turns  over  one  of  the  corners  so  as  to  bring  a  clean  por- 
tion under  the  rima  vulvas.  In  the  majority  of  cases  the  cloths 
need  not  be  changed  until  one  and  a  half  hours  post-partum.  After 
the  lapse  of  this  time  the  orifice  of  the  urethra  is  touched  lightly 
with  cotton  and  sublimate  solution,  the  urine  drawn,  and  the 
placenta  expressed  thus.  The  attendant  grasps  the  fundus  with 
four  spread  fingers,  whose  tips  are  directed  towards  the  lumbar 
vertebrae  (passing  along  the  posterior  wall  of  the  fundus  and  corpus 
uteri),  the  thumb  resting  on  the  anterior  wall.  The  uterus  being 
brought  into  the  mid-line,  the  fingers  are  alternately  con- 
tracted towards  the  fundus  and  extended  along  the  uterus  ;  as  the 
latter  hardens  pressure  is  exerted  mainly  with  the  ball  of  the  thumb 
on  the  fundus,  when  the  placenta  begins  to  emerge  from  the  rima 
vulvai.  Usually  the  patient  now  completes  the  expulsion  by  volun- 
tary effort.  Care  is  had  that  the  placenta  emerges  slowly  from  the 
vulva,  lest  the  membranes  be  torn.  Again  the  external  genitals 
are  carefully  cleansed  with  cotton  or  wool  dipped  in  sublimate 
solution,  and  the  manipulation  is  completed.  When  continuous 
hasmorrhage  ensues  which  is  not  due  to  injuries,  massage  is  per- 
formed ;  if  arrested,  the  expectant  method  is  resumed,  and  the 
placenta  expressed  after  one  and  a  half  hours.  If  massage  fails, 
the  expulsion  of  the  placenta  is  considered  abnormal,  and  early 
expression  indicated.  The  physician  must  ever  be  conscious  that  in 
performing  Crede's  method  he  is  disturbing  a  physiological  process. 
The  responsibility  for  the  consequences  due  to  this  disturbance 
must,  unquestionably,  be  assumed  by  the  physician. 

The  Treatment  of  the  Third  Stage  of  Labour  (discussion 
at  the  German  Gynsecological  Association,  Amer.  Jour,  of  Ohst.) — 
Dohrn  read  a  paper  on  the  question  of  the  treatment  of  the 
third  stage  of  labour,  illustrated  by  diagrams.  After  Dohrn 
had  stated  that  he  to-day  held  essentially  the  same  views  he  had 
expressed  as  early  as  1880,  he  pointed  out  the  advantage  of  Credo's 
method,  but  predicted  a  great  future  for  the  expectant  plan.  On 
plate  i.  he  demonstrated  the  Lemser-Schultze  mode  of  separating 
the  placenta,  the  retro-placental  haemorrhage,  which  at  the  same 
time  acts  as  a  tampon  and  assists  the  propulsion  of  the  placenta, 
he  estimates  as  a  result  of  500  observations  at  an  average  of  305 
grammes.  He  considers  this  method  as  the  more  frequent  in  the 
ratio  of  4  to  1 ;  plate  ii.  delineates  the  method  of  Duncan,  in  which 
the  placenta  emerges  by  its  margin ;  plate  iii.  represents  the  old 


854  PERISCOPE.  [march 

method,  traction  on  the  cord;  plate  iv.  shows  Credo's  method 
correctly  employed ;  plate  v.  the  same  incorrectly  used.  Dr 
Fehling,  Basle,  spoke  of  the  mechanism  of  placental  separation. 
While  in  Germany  Schultze's  views  had  found  the  most  adherents, 
gynaecologists  in  America  advocated  those  of  Duncan.  Of  81  cases 
he  observed  in  57  Duncan's,  in  5  Schultze's,  and  in  19  the  mixed 
mode  of  separation.  He  considers  the  mode  of  Duncan  the  usual 
one,  that  of  Schultze  occurs  mainly  through  traction  upon  the  cord. 
The  retro-placental  effusion  of  blood  can  have  no  influence  on  the 
detachment  of  the  placenta ;  it  can  at  most  take  place  only  after 
the  first  pain,  of  which  fact  he  had  convinced  himself  by  experi- 
ments under  chloroform.  The  bleeding  is  arrested  by  thrombi, 
resulting  from  the  retro-placental  haemorrhage.  In  the  discussion 
of  the  last  two  papers,  the  following  gentlemen  participated : — 
Schatz,  Rostock — In  practice  the  expectant  plan  was  not  possible ; 
the  loss  of  blood  is  considerable.  Winckel  observed  in  100  cases 
79  where  Schultze's  mode  of  separation  occurred.  He,  too,  employs 
the  expectant  plan,  but  expresses  the  placenta  after  two  hours. 
Haemorrhage  is  always  present.  Lahs  is  in  favour  of  the  modified 
Ci'ede  procedure,  and  considers  Duncan's  the  more  frequent  mode 
of  separation.  Ahlfeld  saw  no  haemorrhage  before  the  expulsion  of 
the  placenta  in  40  per  cent,  of  the  cases.  The  loss  of  blood  in  the 
first  hours  amounted  on  the  average  to  495  grammes.  Secondary 
liaemorrhage  did  not  occur.  In  the  last  five  or  six  years  he  had 
not  found  it  necessary  to  use  any  styptics  in  his  procedure ;  at  most 
here  and  there  massage  was  required.  The  expectant  plan  is  not 
applicable  where  haemorrhage  is  present.  The  placenta  had  to  be 
manually  separated  in  but  0*3-0'4  per  cent,  of  the  cases,  with  Crede's 
method  in  7  per  cent.  In  closing  the  discussion,  Dohrn  remarked 
that  the  first  detachment  of  the  placenta  was  caused  by  contractions, 
after  which  the  effusion  of  blood  comes  into  play.  Among  1000 
cases,  he  resorted  to  Credo's  method  only  when  the  need  was  urgent, 
otherwise  he  followed  the  expectant  plan  like  Winckel. 


PERISCOPE  OF  SYPHILOLOGY. 

By  Francis  Cadell,  F.R.C.S.  Ed. 

An  Address  on  Syphilis. — This  address  was  delivered  by  Dr 
Henry  FitzGibbon  at  the  opening  meeting  of  the  Surgical  Section 
of  the  Royal  Academy  of  Medicine  in  Ireland,  session  1888-89. 
A  short  account  of  the  history  of  syphilis  is  given,  where  the  author 
adheres  to  the  hypothesis  of  the  ancient  origin  of  syphilis.  In 
considering  the  manner  of  invasion  of  syphilis,  he  has  only  time  to 
speak  of  that  by  contagion.  He  believes  that  the  chancre  and 
chancroid  are  distinct  forms  of  disease,  but  that  gonorrhoea  may  on 
rare  occasions  be  the  sole  primary  lesion  of  syphilis.  A  case  is 
noted  where  infection  by  contact  and  direct  absorption,  or  luhon 


1889.]  PERISCOPE   OF   SYPHILOLOGY.  855 

d'emhle^,  was  apparently  the  only  explanation  of  the  infection.  No 
abrasion  or  excoriation  whatever  was  found.  Another  similar  case 
occurred  to  him. 

The  following  is  an  interesting  case  of  syphilis  of  the  innocent. 
A  rich  banker,  whose  reputation  for  propriety  of  conduct  was  his 
greatest  pride,  contracted  a  Hunterian  cliancre  upon  his  lower  lip. 
With  pardonable  indignation  he  told  his  family  physician  that  he 
was  a  liar  when  he  announced  to  him  the  nature  of  the  disease. 
It  subsequently  transpired  that  he  had  inoculated  his  lip  with  his 
finger  when  counting  a  roll  of  bank  notes  which  had  been  recovered 
from  a  prostitute  who  had  stolen  them  from  one  of  his  clerks.  The 
woman  had  concealed  the  roll  in  her  vagina.  A  more  painful  case 
was  that  of  a  young  lady,  only  14  years  of  age,  who  unaccountably 
developed  a  profuse  papular  syphilide.  She  had  an  induration  on 
the  right  thigh  a  little  above  the  knee.  This,  she  said,  was  where 
the  crutch  of  her  saddle  had  cut  her  six  weeks  previously,  when 
taking  a  riding  lesson.  The  recent  abrasion  had  then  become 
infected  by  virus  from  the  seat  of  a  closet  at  a  railway  station. 
Among  the  poor,  he  thinks,  the  acarus  sabici  often  conveys  syphilis. 
Chaste  mothers  and  sisters  have  been  contaminated  by  the  kiss  of 
a  dissipated  son  or  brother.  Healthy  children  have  been  infected 
by  nurses.  Midwives  have  spread  the  disease.  Hardy  states  that 
a  specialist  in  Paris  inoculated  forty  or  fifty  persons  with  a  Eustachian 
catheter.  Vaccination  is  supposed  to  be  a  source  of  public  danger, 
but  it  reflects  credit  and  honour  on  our  public  vaccinators,  that  for 
many  years  contamination  of  healthy  children  in  this  way  is  prac- 
tically unknown.  Preventive  treatment  by  C.  D.  Acts  is  strongly 
insisted  upon.  By  the  judicious  and  rational  use  of  mercury,  by 
enforcing  temperance,  by  regulating  digestion,  by  prohibiting  ex- 
posure to  extremes  of  temperature,  and  by  the  proper  administration 
of  baths,  we  know  now  that  syphilis  can,  like  other  eruptive  fevers, 
be  cured  and  wholly  eliminated  from  the  system.  The  proof  of  this 
is  the  fact  that  an  individual  can  have  a  second  attack  of  syphilis. 
Zeissl's  dictum,'  '  That  a  man  who  once  has  syphilis  has  it  for  ever, 
and  that  his  ghost  after  death  will  still  be  syphilitic,"  is  proved  to 
be  untrue. 

Dr  Keyes,  of  New  York,  read  a  paper  on  "  The  Curability  of 
Urethral  Stricture  by  Electricity."  Observations  were  made  on  six 
selected  cases  favourable  for  testing  the  method.  Two  were  treated 
by  himself,  three  by  Dr  Fuller,  his  assistant,  and  one  by  Dr  Newman 
in  Dr  Fuller's  presence.  In  all  cases  the  result  was  non-success. 
Dr  Keyes  believes  that  the  claims  made  for  the  method  are  not 
supported  by  clinical  demonstration. 

Dr  F.  S.  Watson. — As  a  contribution  coming  from  an^'entirely 
independent  source,  I  would  like  to  mention  a  little  experience  with 
electrolysis  in  urethral  stricture  of  my  own.  The  results  were 
similar  to  Dr  Reyes's.     The  number  of  cases  was  six,  and  all  the 


856  PERISCOPE.  [march 

rules  laid  down  by  Dr  Newman  were  observed.  In  no  one  of  the 
cases  was  there  a  successful  result.  In  the  best  case  a  sound  two 
sizes  larger  than  could  at  first  be  introduced  was  passed  at  the  end 
of  several  weeks'  treatment.  In  the  first  case,  after  electrolysis  had 
been  resorted  to  without  success,  the  stricture  was  cut. 

Br  L.  B.  Bangs. — I  have  had  some  experience  with  the  treatment 
of  stricture  by  electricity.  After  having  gone  a  certain  distance 
with  it,  I  got  so  disgusted  that  I  gave  it  up.  Nevertheless  the 
impression  seems  to  be  gaining  ground,  not  only  in  the  profession 
but  also  among  the  laity,  that  we  now  have  a  means  of  positively 
curing  stricture  without  causing  pain.  I  believe  it  is  altogether  a 
false  impression. 

Br  F.  B.  Sturgis. — My  experience  was  one  dating  back  some 
years  ago,  when  this  treatment  first  came  up.  I  found  that  it  did 
much  more  harm  than  good.  But  there  resulted  so  much  pain  and 
bleeding,  and  I  was  so  fearful  of  doing  damage,  that  I  gave  it  up 
since  no  good  came  from  it. 

Br  Tilden  Brovm^  by  invitation. — I  need  hardly  say  that  I  have 
listened  with  interest  to  the  reading  of  the  paper,  particularly  as  it 
confirms  experiments  made  by  myself.  The  only  thing  which 
occurs  to  me  as  confirmatory  evidence  of  wliat  I  consider  the 
utter  futility  of  the  method,  is  the  fact  that  after  I  had  read  my 
paper,  which  has  been  alluded  to,  Dr  Newman  kindly  came  up  and 
spoke  to  me,  and  a  gentleman  present  suggested  that  Dr  Newman 
take  the  second  case,  which  I  reported,  which  had  been  so  pro- 
nounced a  failure,  and  treat  it.  He  objected  on  the  score  of  being 
too  busy.  We  urged  him,  and  assured  him  the  full  fees  would  be 
paid  for  the  treatment,  but  despite  tliat  fact  he  declined  to  accept 
the  case.  I  told  him  that  if  he  would  take  the  case  and  cure  it,  I 
would  devote  all  my  future  to  extolling  the  method,  but  it  was 
fruitless. 

The  President  (Dr  Keyes). — I  can  only  say,  in  closing  the 
discussion,  that  it  is  a  great  pity  to  have  to  raise  the  question  at  all, 
but  the  method  is  gaining  credence  in  the  mind  of  the  public,  and 
some  medical  gentlemen  have  come  out  in  favour  of  it.  I  have 
even  seen  a  notice  of  some  one  curing  strictures  of  the  rectum  by 
electricity.  It  is  a  sort  of  faith  cure.  I  began  the  study  of  the 
method  because  patients  came  to  me  and  wanted  to  be  treated  by 
electricity.  I  acknowledged  ignorance  of  the  method,  and  indiffer- 
ence toward  it,  but  I  had  no  foundation  for  my  non-belief,  for  no 
man  should  accept  his  belief  second-hand ;  I  had  not  made  experi- 
ments. But  now  I  have  made  them  with  the  results  recorded  in 
my  paper. — Journal  of  Cutaneous  and  Genito- Urinary  Biseases, 
December  1888. 

Syphilis  as  a  Non- Venereal  Disease. — In  the  Journal  of  the 
American  Medical  Association,  Dec.  22nd,  1888,  Dr  Bulkley 
remarks   that  three   main  groups  or  varieties   of  cases  of  non- 


1889.]  PERISCOPE   OF   SYPHILOLOGY.  857 

venereal  infection  of  syphilis  may  readily  be  made  out,  according  as 
the  inoculation  takes  place: — 1.  Among  those  having  common 
relations,  and  through  the  bonds  of  common  interest  in  domestic 
and  industrial  life ;  to  this  class  the  term  syphilis  economica  has 
been  given.  2.  Among  infants  and  those  having  to  do  with  their 
care  and  nourishment,  or  syphilis  hrephotrophica ;  and  3.  In  con- 
nexion with  the  various  forms  of  body-service,  medical  and  surgical, 
or  of  like  nature — syphilis  technica.  In  each  of  these  groups  we 
will  find  a  large  number  of  subdivisions,  amounting  to  over  one 
hundred,  representing  different  modes  of  communicating  the  disease 
which  have  thus  far  been  recorded  in  literature.  These  divisions 
may  now  be  considered  a  little  more  in  detail. 

1.  Syphilis  Economica. — Infection  may  come  from  spoons,  knives, 
forks,  cups,  glasses,  and  jugs.  Tobacco  pipes  and  cigars  have  been 
the  means  of  transmission.  "Wearing  apparel  has  conveyed  syphilis  ; 
as  also  lint,  plaster ;  likewise  bedding  and  toilet  articles,  syringes 
and  tooth  brushes.  No  authentic  case  of  infection  from  privy  seats 
has  been  recorded.  An  opera  glass  and  a  cane  have  also  conveyed 
the  poison.  Among  trades,  glassblowers  and  goldsmiths  have  each 
suffered  from  the  blowing  tools  passed  from  mouth  to  mouth. 
Musicians  have  acquired  the  disease  in  a  similar  way,  and  a  car- 
conductor  from  a  whistle  borrowed  from  a  syphilitic  friend.  Three 
furriers  were  diseased  by  the  thread  drawn  through  their  lips.  An 
artificial  flower  maker  was  infected  through  her  handiwork,  and  an 
instance  where  tack-nails  passed  from  the  mouth  of  one  upholsterer 
with  mucous  patches  to  another  conveyed  the  poison  to  abrasions 
caused  by  the  nails  is  mentioned.  Paper  money  and  coins  may 
also  be  mentioned  as  causes  of  infection.  Kissing,  next  to  the 
venereal  act,  is  the  most  prolific  source  of  propagation. 

2.  Syphilis  Brephotrophica. — Infants  frequently  spread  the  disease 
either  to  wet-nurses  or  by  means  of  their  feeding-bottles.  Scratches 
and  tooth  wounds  inflicted  by  syphilitic  infants  have  repeatedly 
given  rise  to  chancres,  while  a  large  number  of  infants  have 
received  an  extra  genital  chancre  from  the  kissing  and  fondling  of 
syphilitic  adults. 

3.  Syphilis  Technica. — Physicians,  surgeons,  accoucheurs,  and 
midwives  have  all  been  frequently  infected  in  the  pursuit  of  their 
profession,  more  especially  the  two  latter  classes.  Chancres  have 
also  been  produced  on  different  parts  of  the  face  by  the  fingers  of 
physicians  and  attendants  conveying  the  virus.  Physicians  and 
midwives  have  also  spread  the  disease  from  their  own  persons 
while  attending  patients.  A  rather  curious  mode  of  propagating 
syphilis  innocently  is  found  in  the  practice  of  removing  particles 
from  the  eye  by  means  of  the  tip  of  the  tongue.  In  two  small 
villages  in  Russia,  Tepljaschin  found,  among  a  population  of  532 
persons,  no  less  than  68  individuals,  23  males  and  45  females, 
affected  with  syphilis,  about  one-quarter  of  them  being  under  10 
years  of  age.     One-half  of  the  entire  number  had  been  infected 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO,   IX.  5  Q 


858  PERISCOPE.  [march 

directly  by  a  female  quack  who  had  followed  the  industry  of 
removing  foreign  bodies  from  the  eye,  and  treating  trachoma,  with 
her  tongue.  The  woman  became  infected  in  her  calling,  and 
pursued  it  while  diseased,  with  the  results  mentioned.  A  number  of 
single  instances  of  the  same  method  of  infection  have  been  recorded, 
two  of  which  occurred  in  this  country.  Wound  sucking  has  given 
syphilis  to  the  operator  and  also  to  the  person  operated  on.  Many 
cases  have  been  recorded  of  infection  from  tattooing.  Vaccination, 
ritual  circumcision,  transplantation  of  teeth,  wet-cupping,  minor 
surgical  operations.  Eustachian  and  other  forms  of  catheterization, 
have  all  been  reported  as  frequent  sources  of  infection. 


OCCASIONAL  PERISCOPE  OF  SURGERY. 
Edwin  G,  Bull,  M.B. 

PoNCET  ON  Adeno-Chondroma  OF  Palate. — The  patient  was 
a  man  aged  57.  On  admission  to  the  H6tel  Dieu  at  Lyons  he 
was  suffering  from  extreme  dyspnoea  and  cyanosis.  These  symp- 
toms had  come  on  during  the  past  five  days,  though  the  tumour 
had  been  in  existence  for  three  years.  An  enormous  hard  elastic 
tumour  was  found  springing  from  the  right  side  of  the  soft  palate 
and  filling  the  entire  pharynx.  In  spite  of  tracheotomy,  the  patient 
died  on  the  evening  of  his  admission.  At  the  autopsy  the  growth 
was  found  to  be  of  the  size  of  a  China  orange ;  it  weighed  150 
grammes,  was  non-adherent,  and  presented  all  the  clinical  features 
of  an  adenoma.  The  microscope  showed  (1),  scanty  epithelial 
elements ;  (2),  various  forms  of  connective  tissue,  especially  mucous 
and  cartilaginous.  The  growth  thus  proved  to  be  an  adeno-chon- 
droma  or  myxo-chondroma.  Timely  operation  would  have  saved 
the  patient.  Suffocation  as  the  result  of  tumour  of  the  soft  palate 
is  amongst  the  greatest  of  surgical  rarities  (Poncet,  Gaz.  d.  Hop., 
1888,  70).— JafFe  in  Centmlb.f.  Chirurgie. 

BosE  on  Bloodless  Extirpation  of  Tumours  of  the  Thyroid 
Gland. — In  most  cases  of  goitre  the  disease  only  affects  portions  of 
lobes,  whilst  around  we  find  healthy,  though  perhaps  somewhat 
atrophied,  tissue.  "  Intra-glandular  extirpation  "  is  thus  possible, 
and  is  by  no  means  so  dangerous  as  total  removal,  for  we  avoid 
cachexia  strumipriva,  wounds  of  neighbouring  vessels  and  nerves, 
and  secondary  haemorrhage.  The  deep  cellular  tissue  planes  are 
not  opened,  and  less  deformity  results.  On  the  other  hand,  whilst 
extirpation  is  easy  if  the  capsule  of  the  nodule  be  thin  and  encoun- 
tered at  once,  dangerous  bleeding  may  follow  the  division  of  the  latter 
if  thick,  and  the  operator  may  be  compelled  to  proceed  to  total  extirpa- 
tion. Adhesions  of  the  capsule  to  its  environment  may  cause  diffi- 
culty. In  one  case,  not  being  able  to  distinguish  between  morbid  and 
sound  tissue,  Bose  supposed  he  had  to  do  with  a  difi'use  disease,  and 
proceeded  to  remove  the  entire  thyroid.     But  subsequent  examina- 


1889.]  OCCASIONAL  PERISCOPE  OF   SURGERY.  $5^ 

tion  showed  that  distinct  nodules  were  present,  which  could  have 
been  shelled  out  if  their  true  location  had  been  known.  In  three 
subsequent  operations  he  adopted  the  following  method  of  pro- 
cedure with  success.  The  cutaneous  incision  begins  (in  cases 
where  a  lateral  lobe  is  effected)  in  the  jugular  region  {jugulum), 
and  runs  over  the  summit  of  the  tumour  outwards  and  upwards 
towards  the  angle  of  the  lower  jaw.  If  both  sides  be  diseased,  the 
second  can  be  attacked  at  a  second  sitting.  The  superficial  fascia, 
the  platysma,  and  subjacent  muscles  immediately  covering  the 
gland  are  then  divided  in  the  same  direction.  The  gland  capsule 
is  exposed,  and  the  surrounding  loose  cellular  tissue  divided  later- 
ally to  a  moderate  extent  with  the  finger.  The  part  of  the  gland 
affected  can  then  be  so  elevated  that  half  the  diameter  of  the  tumour 
projects  through  the  incision.  Held  in  this  position  for  a  short 
time  the  quantity  of  contained  blood  is  largely  diminished.  An 
elastic  ligature  is  passed  round  the  tumour,  just  behind  its  greatest 
circumference  and  close  to  the  cutaneous  incision.  The  diseased 
nodules  are  now  shelled  out  with  but  little  haemorrhage  occurring, 
and  the  ligature  gradually  contracts  round  a  sort  of  pedicle  formed 
of  sound  tissue.  Removal  of  ligature  is  followed  by  very  slight 
bleeding,  and  in  no  case  did  the  wound  cavity  require  plugging. 
After  disinfection  of  the  latter  a  drainage-tube  is  introduced  at 
the  posterior  angle  of  the  wound,  and  the  divided  tissues  (gland, 
muscle,  skin)  are  sutured  separately  with  catgut.  The  tube  is 
removed  on  the  second  day,  and  healing  is  completed  under  the 
second  dressing.  The  procedure  just  described  may  also  be  followed 
in  cases  of  cystic  disease,  but  is  of  course  unavailable  when  the  tumour 
has  become  fixed  by  undermining  the  sternum  or  trachea. — Prof. 
Bose  in  Centralh.fiir  Chirurg.,  No.  1,  1889. 

KoNiG  ON  THE  Use  of  Broad  Chisels  in  Osteotomy. — Prof. 
Konig  remarks  that  he  has  used  such  chisels  (3  to  5  cm.  =  1  ^  to 
1^  inches  broad)  for  a  number  of  years,  and  attains  his  object 
thereby  with  a  minimum  expenditure  of  time  and  force.  He  gives 
a  few  examples  of  cases  to  which  broad  chisels  are  suitable.  1. 
Ankylosis  of  knee  at  an  obtuse  angle.  2.  Badly  united  fractures 
of  shaft  of  femur  with  high  degree  of  outward  convexity.  3. 
Division  of  femur  (M'Ewan)  in  genu  valgum.  Concluding,  Konig 
says :  In  order  to  attain  the  most  uniform  section  with  the  least 
delay,  one  must  use  a  good  broad  chisel ;  and,  secondly,  the  latter  is 
not  to  be  applied  vertically,  but  obliquely  to  the  axis  of  the  bone. — 
Konig  in  Gentralb.  filr  Chirurg.,  No.  1,  1889. 

Radestock  on  Laryngeal  Carcinoma. — At  the  end  of  1882 
the  patient,  a  man  aged  22,  became  afiected  with  hoarseness.  In 
June  1884  aphonia  and  dyspnoea  suddenly  set  in,  and  tracheotomy 
became  necessary  in  the  middle  of  August.  In  February  1887 
a  further  growth  below  the  vocal  cords  was  suspected,  and  thyrotomy 
(laryngofissure)   was  performed.      As  it  was  now  found  that  the 


860  pEEiscoPE.  [march 

greater  part  of  the  thyroid  cartilage  wa8  destroyed  by  the  cancerous 
growth,  total  extirpation  of  the  larynx  was  resolved  on.  A  portion 
of  the  trachea  as  far  down  as  the  incisura  semilunaris,  as  well  as  a 
cancer  nodule  in  the  left  lobe  of  the  thyroid  gland,  were  at  the 
same  time  removed.  Healing  was  uneventful,  and  on  the  twenty- 
third  day  a  Gussenbauer's  larynx  was  introduced.  At  the  begin- 
ning of  1888  the  patient's  general  condition  was  good,  but  the 
phonation  apparatus  proved  a  failure,  and  was  used  merely  as  a 
respiration  cannula  (Radestock,  ArcMv  f.  hlin.  Chir.,  Bd.  xxxvii., 
pp.  226-231).— F.  Bessel-Hagen  in  Centmlb.f.  Chirurg.,  No.  1, 1889. 

K  Gamaleia  on  Etiology  of  Chicken  Cholera. — Gamaleia's 
researches  prove  that  the  bacillus  of  chicken  cholera  is  constantly 
present  in  the  intestinal  canal  of  pigeons  without  producing  patho- 
logical results,  in  this  respect  resembling  Pasteur's  vihrion  septique 
occurring  in  the  intestine  of  mammals,  Gamaleia  proposes  to 
name  the  former  cocco-hacillus  avicidus.  It  becomes  more  virulent 
after  passing  through  a  rabbit  (N.  Gamaleia,  Gentralb.  fur  Bakter., 
Bd.  iv..  No.  6).— Garr6  in  Centralb.  /.  Chir.,  No.  2,  1889. 

Verneuil  on  Microbism  and  Abscess. — Verneuil  proposes  to 
no  longer  classify  abscesses  as  hot  and  cold,  idiopathic  and  sympto- 
matic, but  etiologically,  according  to  the  nature  of  the  bacteria  that 
produce  them.  For  our  modern  knowledge  of  the  process  of  sup- 
puration we  have  to  thank  three  methods — microscopic  researches 
with  staining  reagents,  cultures,  and  inoculation  experiments.  We 
now  know  that  every  sample  of  pus  contains  bacteria,  and  the 
abscess  contents  may  be  mono-microhique  or  poly-microhique.  The 
bacteria  of  pus  may  be  divided  into  two  groups  :  the  first  are  con- 
stantly present  in  all  pus,  and  are  characteristic  of  it  (the  different 
micrococci  and  diplococci,  streptococci,  Zoogloea,  staphylococcus 
pyog.  aureus,  citricus,  albus,  etc.);  the  second  are  only  found 
occasionally  (various  micrococci,  bacteria,  vibrios,  bacilli,  etc.) 
The  first  Verneuil  calls  pyogenic  microbes  proper;  the  latter, 
accidentally  pyogenic  microbes  ("  pyocoles ").  Verneuil  divides 
abscesses  into — (1),  Simple  abscess,  containing  only  the  "pyogenic 
microbes  proper  J "  (2),  Infecting  abscess,  in  which  the  accidental 
bacteria  also  occur.  He  already  enumerates  sixteen  varieties  of 
abscess  occurring  with  particular  infectious  diseases,  and  contain- 
ing specific  bacteria.  Variola,  syphilis,  and  chancroid  do  not  find 
places  in  the  list,  their  bacteria  not  having  as  yet  been  isolated, 
though  certainly  they  will  yet  be  found  (Verneuil,  France  Med., 
1888,  No.  17).— Jaff^  in  Centralb.  filr  Chir.,  1889,  No.  2. 

Zesas  on  Excision  of  the  Diseased  Thyroid  Gland. — The 
cases  described  (all  non-malignant)  occurred  in  the  surgical  clinic 
of  Niehans  at  Berne  from  the  year  1880  onwards.  Of  the  fifty 
patients  operated  upon,  twenty-three  were  men,  twenty-seven 
women.     One  patient,  who  was  seized  during  her  puerperium  with 


1889.]  OCCASIONAL  PERISCOPE  OF   SURGERY.  861 

severe  strumitis  (inflammation  of  goitre),  and  who  was  tracheo- 
tomized  on  account  of  urgent  dyspnoea,  died,  a  few  days  after  the 
simultaneously  performed  excision,  of  broncho-pneumonia.  Another 
died  of  sepsis.  The  others  recovered  rapidly.  In  three  of  the 
cases  the  typical  features  of  cachexia  strumipriva  showed  them- 
selves later  on.  A  few  other  cases  presented  isolated  symptoms  of 
the  same  condition,  but  soon  recovered.  Zesas  comes  to  tlie 
conclusion  that  Socins's  method  should  be  adopted  in  all  cases  of 
thyroidal  growths  where  enucleation  is  possible.  Where  this  can- 
not be  done,  Kocher's  partial  strumectomy  is  advised  (D.  G.  Zesas 
in  Archiv  filr  k.  Chir.,  Bd.  xxxvi.  p.  733). — F.  Bessel-Hagen  in 
Centralh.  filr  Chirurg.,  No.  2,  1889. 

Bier  on  Acromegaly. — Notices  of  this  disease,  first  described 
by  Marie  in  1886,  are  so  scanty  that  every  fresh  case  deserves 
attention.  The  patient,  apart  from  rickets,  was  in  good  health  up 
to  his  twentieth  year.  From  that  time  the  fingers  gradually 
became  thickened,  with  frequent  ulcerative  break-down  ;  whilst 
later,  the  ears  and  larynx  also  became  affected.  The  sensibility  of 
the  fingers  was  diminished ;  there  was  no  pain ;  the  hypertrophy 
implicated  bone  and  skin.  The  mamma  were  strongly  hyper- 
trophied,  while,  on  the  other  hand,  the  thyroid  gland  had  undergone 
marked  atrophy.  Neuralgia  occurred  in  the  left  arm  and  right  leg, 
and  in  the  right  mamma.  Other  symptoms  described  by  Marie 
were  also  present,  such  as  muscular  weakness,  spinal  curvature 
(cervical),  and  a  tendency  to  varix.  Polydipsia  and  polyuria  were 
not  observed  (Bier  in  Mitt,  ans  der  chir.  Klin,  zu  Kiel,  1888,  iv.) — 
Jadasshon  in  Centralh.  filr  Chirurgie,  1888,  No.  51. 

Grimme  on  Carcinoma  Laryngis. — Grimme  has  examined  the 
post-mortem  records  of  the  Munich  Pathological  Institute  from 
1854  to  1887  inclusive,  and  found  that  among  13,517  sections 
there  were  15  (two  uncertain)  cases  of  laryngeal  cancer.  Of  these, 
seven  were  primary,  seven  secondary,  and  one  doubtful.  The  male 
sex  and  advanced  age  seemed  most  predisposed  to  the  disease. 
Grimme  points  out  the  rarity  of  metastasis  in  laryngeal  cancer,  and 
also  the  fact  that  a  true  cancerous  cachexia  often  occurs  only  very 
late  in  the  case  (B.  Grimme,  Mitnchener  Dissert.,  1888). — P. 
Wagner  in  Gentralb.  filr  Chir.,  1888,  No.  52. 

Crede  on  Operations  on  the  Gall-Bladder. — As  indications 
for  operative  interference  he  regards  lithiasis,  hydrops,  and  empyema 
of  the  bladder,  singly  or  in  combination.  Removal  of  tumours  is 
not  yet  attempted.  Up  to  now  the  methods  in  use  are  five  in 
number — (1),  Simple  cholecystotomy,  i.e.,  simple  incision  into  the 
gall-bladder  after  opening  the  abdominal  cavity  in  one  or  two 
stances ;  (2),  Cholecystotomy  with  sunk  sutures  (Spencer  Wells 
and  Kiister) ;  (3),  Cholecystectomy,  extirpation  of  the  bladder,  first 
carried  out  by  Langenbuch  ;  (4),  Cholecystotomy  with  ligature  and 


862  PERISCOPE.  [march 

resection  of  the  cystic  duct,  done  once  by  Zielewicz;  (5),  Cholecysto- 
tomy  with  formation  of  a  gall-bladder — small  intestine  fistula,  pro- 
posed by  Nussbaum,  and  carried  out  by  Von  Winiwarter.  Cred^ 
regards  methods  2  and  5  as  too  dangerous,  whilst  the  remaining  three 
have  also  certain  disadvantages,  which  perhaps  may  in  time  be 
diminished.  After  simple  cholecystectomy  a  fistula  frequently 
remains.  Cholecystectomy  is  often  accompanied  by  dangerous 
haemorrhage  from  the  liver.  Zielewicz's  operation,  in  the  only  case  in 
which  it  has  been  performed,  was  also  followed  by  the  formation  of  a 
fistula.  Cred^  has  once  extirpated  the  gall-bladder  for  calculus 
and  hydrops.  The  patient,  a  woman  aged  29,  had  suffered  from 
biliary  colic  since  her  eighteenth  year.  After  her  fourth  preg- 
nancy a  painful  swelling  developed  to  the  right  of  the  umbilicus, 
and  the  patient  simultaneously  lost  flesh,  and  earnestly  sought 
operative  help.  Credd  operated  on  23rd  November  1887.  The 
tumour,  which  was  covered  with  old  cicatrices,  and  firmly  adherent 
to  the  liver,  consisted  of  the  gall-bladder.  The  latter  was  ex- 
tracted with  difficulty,  and  contained  150  grammes  of  turbid 
mucous  fluid  and  40  calculi.  It  was  15  cm.  in  length.  On  the 
fifth  day,  the  temperature  rising,  the  wound  w^as  reopened,  and  pus 
and  blood-clot  evacuated.  Complete  healing  followed.  Cred^ 
believes  that  cholecystectomy  should  be  the  usual  procedure,  but  if 
during  operation  extirpation  becomes  clearly  impossible,  simple 
cystotomy  or  Zielewicz's  operation  may  be  had  recourse  to  (Cred^ 
[Dresden]  Sond.  a.  d.  Jahresber.  d.  Gesellsch.  f.  Nat.  u.  Heil.  zu 
Dresden,  1887-8). — Jaffd  in  Ce7itralb.  fitr  Chirurgie,  No.  44,  1888. 


In  our  excellent  contemporary,  the  Medical  Press  and  Circular 
for  30th  January  1889,  Dr  Thomas  Hayes,  the  medical  officer  of 
Rathkeale  Union  Hospital,  gives  an  admirable  account  of  four  cases 
of  serious  gunshot  wound  treated  successfully.  In  the  first,  a  heavy 
charge  of  double  duck  shot  passed  from  the  axilla  to  the  point  of 
the  shoulder.  The  joint  presented  an  excavation  three  or  four 
inches  in  diameter,  filled  with  a  mixed  mass  of  fragments  of  bone, 
cartilage,  blood,  and  debris.  The  axillary  vessels  had  escaped, 
though  the  head  of  humerus,  coracoid  and  acromion  processes,  were 
all  shattered.  The  case  was  conducted  to  an  excellent  recovery, 
with  a  useful  limb,  by  judicious  treatment.  The  second  was  a 
servant  girl,  who  seems  to  have  taken  a  good  deal  of  trouble  to 
shoot  herself  accidentally  with  a  revolver  bullet  between  the  fifth 
and  sixth  left  ribs  within  an  inch  of  the  sternum.  Though  col- 
lapsed, pulseless,  and  vomiting  after  the  accident,  the  bullet  was 
never  found,  and  no  bad  symptoms  followed.  The  third  was  a 
wound  of  hand  caused  by  the  explosion  of  a  rusty  rifle.  The  parts 
were  so  shattered  that  amputation  could  have  been  done  by  scissors, 
but  by  patient  antiseptic  dressing  and  drainage  a  useful  limb  was 
left.     The  fourth  was  a  similar  case,  even  worse,  with  a  similar 


1889.]  OCCASIONAL   PERISCOPE   OF   SURGERY.  863 

good  result.  Dr  Hayes  believes  in  the  virtues  of  what  he  calls  the 
antitetanic  pill,  which  is  1  gr.  each  of  calomel,  aloes,  and  opium,  to 
be  taken  every  night.  The  cases  are  well  told,  and  the  results 
excellent. 


i^att  dFCftl), 


MEDICAL    NEWS. 
THE  EDINBURGH  OBSTETRICAL  SOCIETY. 

The  Jubilee   Meeting   of   the  above  Society  was  held  in  the 
Waterloo  Eooms,  Edinburgh,  on  Friday,  1st  February  1889. 
The  following  gentlemen  were  present : — 

The  President,  DrUn(ierhill,in  the  Chair ;  Dr  Foiilis, Vice-President,  Croupier; 
The  Lord  Provost  of  Edinburgh  ;  Dr  Peel  Ritchie,  President  Royal  College  of 
Physicians ;  Dr  Joseph  Bell,  President  Royal  College  of  Surgeons  ;  Sir  Wm. 
Turner,  Mr  Lawson  Tait,  Prof.  Eraser,  Dean  of  Medical  Faculty  ;  Prof.  Stephen- 
son, Aberdeen ;  Dr  John  Smith,  President  Medico-Chirurgical  Society  ;  Deputy 
Surgeon-General  Fasson,  Dr  Littlejohn,  Dr  Stuart  Nairne,  President  Glasgow 
Gynaecological  Society  ;  Staff-Surgeon  Walsh,  Dr  George  Paterson,  Dr  Chas. 
Bell,  Dr  Harvey  Littlejohn,  Senior  President  Royal  Medical  Society  ;  Prof. 
Simpson,  Dr  Peddie,  Dr  Keiller,  Dr  Sinclair,  Vice-President ;  Dr  Halliday 
Croom,  Dr  Craig,  Dr  Berry  Hart,  Dr  J.  Ritchie,  Dr  Playfair,  Dr  Barbour,  Dr 
Brewis,  Dr  Felkin,  Dr  Ronaldson,  Dr  Haultain,  Dr  Proudfoot,  Dr  A.  Bruce, 
Dr  Matheson,  Dr  Limont,  Newcastle  ;  Dr  Haig  Ferguson,  Dr  Murray  Gibson, 
Dr  Mossop,  Bradford  ;  Dr  Somerville,  Galashiels ;  Dr  Thos.  "Wood,  Dr  P.  H. 
M'Laren,  Dr  G.  A.  Gibson,  Dr  Bramwel],  Dr  Symington,  Dr  Caird,  Dr  Keay, 
Dr  Cathcart,  Dr  Wilson,  Banff;  Mr  R.  R.  Simpson,  W.S.  ;  Mr  Ivison 
Macadam,  &c.,  &c. 

The  President,  in  proposing  the  toast  of  "  The  Queen,"  said  the 
Queen  had  won  our  respect  and  admiration  by  her  great  qualities 
as  a  ruler,  and  she  had  won  our  affection  and  regard  by  her  conduct 
in  all  the  domestic  relations  of  life,  as  a  wife,  as  a  mother,  and  as 
a  woman  ;  and  he  had  much  pleasure  in  asking  them  to  drink  this 
toast  to  the  Queen. 

The  next  toast,  "  The  Prince  and  Princess  of  Wales,  and  the 
other  Members  of  the  Eoyal  Family,"  was  also  proposed  by  the 
President.  In  proposing  it  he  said  these  august  personages  occupy 
a  large  space  in  the  public  eye.  They  have  many  public  and 
social  duties  to  perform,  and  they  always  perform  those  duties 
very  well  indeed.  The  medical  profession  were  much  indebted  to 
them,  for  whenever  they  wanted  a  new  hospital  built,  or  an  old 
one  enlarged  or  rebuilt,  or  any  charitable  work  whatever  per- 
formed, they  had  only  to  call  upon  some  representative  of  them, 
and  they  always  responded  freely. 

"  The  Navy,  Army,  and  the  Reserve  Forces"  was  also  proposed  by 
the  President.  He  said  they  were  all  proud  of  the  vast  extent  of 
their  British  Empire,  and  they  were  all  proud  of  the  great  achieve- 


864  MEDICAL   NEWS.  [MARCH 

ments  by  which  that  empire  had  been  acquired  for  them.  They 
were  all  proud  of  the  services  of  the  Army  and  the  Navy,  which  in 
time  past  had  done  so  much  good  work,  and  which  in  time  to  come, 
when  they  required  it,  would  do  as  well  and  as  good  work  as  before. 
They  had  a  great  and  glorious  record  to  look  upon  — a  great  record  of 
achievements  won,  of  honour  gained,  and  of  great  battles,  not  only 
fought,  but  won.  The  reserve  forces  had  sprung  into  being  in 
time  of  considerable  danger,  and  tliey  had  increased  every  year  in 
vigour  and  efficiency ;  and  although  they  all  hoped  that  they  might 
continue  to  increase,  and  be  the  best  soldiers  that  they  could  turn 
out,  still — and  he  thought  all  would  agree  with  him — he  hoped  the 
time  would  be  very  far  distant  when  they  would  be  called  upon 
for  active  service.  He  coupled  the  toast  with  the  names  of  Staff- 
Surgeon  Walsh,  Dep.-Surgeon-General  Fasson,  and  Sir  William 
Turner. 

Staff- Surgeon  Walsh,  B.H.,  replying  to  this  toast  for  the  Navy, 
said  the  affairs  of  the  Navy  had  been  so  much  discussed  in  public 
print  of  late  that  he  felt  it  would  be  impossible  for  him  to  tell 
them  anything  about  the  service  that  they  did  not  already  .know  ; 
and  he  thought  if  he  were  to  attempt  to  say  very  much  he  would 
be  pretty  sure  to  bore  them.  This  he  thought  he  should  say,  that 
the  Navy  was  not  in  as  good  a  condition  as  it  should  be.  He 
thought,  however,  the  deliberations  which  had  taken  place  of  late 
would  have  the  result  of  making  it  stronger,  and  then  he  hoped 
the  service  would  be  able  to  do  as  good  work  as  it  had  done  in 
time  past. 

Dep.-Surgeon-General  Fasson,  replying  to  this  toast  on  behalf  of 
the  Army,  said — After  all  the  good  things  the  President  had  said 
about  them  (the  Army,  etc.),  it  was  unnecessary  for  him  to  do 
more  than  to  thank  them  for  the  kind  expressions  made. 

Sir  William  Turner,  replying  for  the  Eeserve  Forces,  said  the 
representatives  of  the  Navy  and  Army  had  set  them  admirable 
example  about  the  extreme  brevity  of  their  speeches,  and  he  did 
not  think  it  would  be  right  in  him,  representing  that  very  inferior 
part  of  the  service,  the  Reserve  Forces,  to  attempt  to  surpass 
them  in  the  length  of  his  speech,  or  in  the  eloquent  terms  in  which 
he  responded  to  the  toast.  There  was  always  one  comfort,  he  felt 
sure,  that  one  must  feel  in  replying  to  such  a  toast  before  an 
assembly  of  this  kind — an  assembly  so  largely  composed  of  men 
whose  business  it  was  to  increase  the  reserve  forces ;  and  all  he 
could  say  in  regard  to  the  matter  was,  in  the  words  of  the  motto 
at  the  foot  of  the  toast  list,  "  Floreat  Lucina."  May  you  long 
preside  over  happy  labours. 

The  Secretary  here  read  a  list  of  apologies  from  the  following 
gentlemen  who  were  unable  to  be  present : — 

Dr  Matthews  Duncan,  London ;  Dr  Oldham,  London ;  Dr  Chas.  West, 
London  ;  Dr  Barnes,  London  ;  Dr  J.  Williams,  President  Obstetrical  Society  ; 
Prof.  Leishman,  Glasgow  ;  Dr  Chas.  Clay,  Manchester ;  Prof.  Kirkpatrick, 


1889.]  THE   EDINBUKGH   OBSTETRICAL    SOCIETY.  865 

Dublin ;  Dr  Edis,  President  British  Gynaecological  Society ;  Dr  Thomas 
Keith,  London  ;  Dr  Braxton  Hicks,  London  ;  Sir  Douglas  Maclagan,  Vice- 
President  Royal  College  of  Physicians  ;  Dr  Argyll  Robertson,  Vice-President 
Royal  College  of  Surgeons  ;  Dr  Morton,  President  Faculty  of  Physicians  and 
Surgeons,  Glasgow  ;  Sir  William  Muir,  Principal  of  the  University. 

The  next  toast  was  "  The  Edinburgh  Obstetrical  Society,"  and 
the  President,  on  rising  to  propose  it,  said — They  were  all  aware 
that  they  were  gathered  that  evening  for  the  purpose  of  cele- 
brating the  fiftieth  session  of  the  Society.  He  said  fifty  years  was 
an  overwhelming  space  in  the  history  of  any  individual,  and  it  was 
no  inconsiderable  space  in  the  history  of  our  race  ;  and  he  doubted 
whether,  in  any  fifty  years  of  which  they  had  any  record,  greater 
advances  had  been  made  in  all  the  many  relationships  of  civilized  life 
than  in  those  last  fifty  years — in  certain  directions  ;  in  all  direc- 
tions which  led  to  the  material  advancement  of  man;  to  his 
greater  comfort ;  to  freedom  of  communication  between  man 
and  man,  and  continent  and  continent :  in  all  these  there  had, 
he  thought,  been  great  advancement.  In  all  the  natural  sciences, 
and  in  our  conceptions  of  the  powers  and  possibilities  of 
science  in  general,  the  world  had  made  mighty  strides,  and  in 
that  one  small  branch  which  this  Society  is  meant  to  cultivate,  he 
thought  they  might  clearly  say  that  they  had  advanced  at  least 
pari  passu  with  the  rest.  This  branch  of  medical  science,  although 
small,  was,  he  thought,  one  of  the  utmost  importance,  because  it 
was  their  business  to  preside  over  the  birth  of  the  race,  and  to  look 
after  the  individual  in  its  earliest  and  most  defenceless  state.  He 
would  remind  them  that  fifty  years  ago  there  was  no  railway 
communication  between  England  and  Scotland,  there  were  no 
telegraphs, — that,  in  point  of  fact,  as  somebody  had  put  it,  within 
these  fifty  momentous  years  the  political  organism  had  developed 
a  new  circulation  which  was  called  steam,  and  a  new  nervous  system 
which  was  called  electricity.  And,  to  turn  to  their  own  profession,  he 
would  remind  them  that  fifty  years  ago  they  had  no  chloroform,  and 
they  had  no  aseptic  midwifery  :  fifty  years  ago  every  surgeon, 
almost  without  exception,  who  came  across  an  ovarian  tumour,  satis- 
fied himself  by  tapping  it  instead  of  applying  the  knife,  as  was  now 
done  ;  and  fifty  years  ago  every  surgeon,  without  any  exception 
whatever,  when  he  came  to  a  case  of  a  ruptured  tubal  pregnancy, 
allowed  the  woman  to  die  unrelieved.  For  the  advances  in  this 
direction  all,  he  said,  knew  to  whom  they  owed  their  thanks — it  was 
to  the  distinguished  surgeon  on  his  left,  Mr  Lawsou  Tait.  It  was 
at  this  time,  in  the  winter  of  1839,  that  it  occurred  to  a 
number  of  medical  men  practising  ]\Iidwifery  in  Edinburgh 
that  it  would  be  a  good  thing  to  unite  and  form  a  Society 
having  for  its  definite  object  the  advancement  of  obstetric  medicine, 
by  means  of  holding  meetings  for  the  purpose  of  receiving  com- 
munications and  conversing  on  subjects  connected  with  that 
branch  of  medicine.     That  idea  was  put  into  practical  form  very 

EDINBURGH   JIED.    JOURN.,    VuL.    XXXIV. — KG.    IX.  5r 


866  MEDICAL   NEWS.  [MARCH 

shortly  afterwards,  and  twenty  original  members  formed  the 
Society.  Of  these  twenty  original  members  six  were  still  living, 
and  he  was  very  happy  to  say  that  out  of  the  six  living  there  were 
three  present  this  evening.  They  were  Dr  George  Paterson,  Dr 
Charles  Bell,  and  Dr  Peddie.  The  remaining  three  who  were  still 
alive  were  Dr  Moir,  Dr  Malcolm,  and  Dr  Graham  Weir.  Most  of 
the  six  gentlemen  still  living  had  been  engaged  in  the  practice  of 
this  branch.  Dr  Paterson,  however,  early  fell  away  from  grace, 
and  went  off  into  the  much  less  genial  branch  of  lunacy.  He 
thought  it  was  a  matter  of  congratulation  that  such  a  large  pro- 
portion as  six  out  of  the  twenty  should  have  survived  all  the 
harassing  work,  the  wasted  nights,  and  the  hard  labours  which 
this  branch  of  the  medical  profession  entails.  The  first  President 
of  this  Society  was  Dr  W.  Beilby,  and  at  the  first  meeting  of  the 
new  Society  the  names  of  Dr  J.  Y.  Simpson  and  Dr  R  Paterson 
of  Leith,  the  latter  of  whom  still  survived,  were  proposed  as  mem- 
bers, and  at  the  next  meeting  they  were  duly  elected.  The 
Society,  with  Dr  Beilby  for  its  President,  began  its  work,  and 
when  he  resigned  the  office  after  two  years,  he  was  followed  by 
Sir  James  Simpson,  who  held  the  office  for  a  number  of  years  from 
1842  to  1857,  and  he  again  held  office  in  1866  and  1867.  In 
addition  to  this  great  name  he  could,  he  thought,  look  back  with 
great  satisfaction  upon  the  list  of  our  Presidents,  and  he  did  not 
think  the  Society  could  have  been  better  served.  The  following 
also  had  held  office  as  Presidents : — Dr  Moir,  Dr  Keiller,  Dr 
Matthews  Duncan,  Dr  Macdonald,  Prof.  A.  K.  Simpson  (twice),  Dr 
Halliday  Croom,  and  others.  For  the  first  year  or  two  of  the 
Society's  existence  it  met  in  the  New  Town  Dispensary,  but  it 
soon  grew  too  large  to  meet  there.  It  then  met  in  the  houses  of 
various  members.  After  a  time  it  went  back  to  the  Dispensary, 
and  finally  obtained  a  home  in  its  chambers  in  St  Andrew  Square 
about  the  year  1865.  The  Society  had  grown  very  largely  within 
the  last  few  years.  From  20  in  1839,  the  Society  now  numbered 
about  300.  There  were  98  Corresponding  Fellows,  and  there  were 
about  20  Honorary  Fellows.  He  might  observe  that  this  Society 
in  its  humility  at  first  called  its  members  "  Members,"  but  about 
thirty  years  ago,  finding  that  the  corresponding  body  in  London 
called  its  members  "  Fellows,"  this  Society  thought  they  had  quite 
as  much  right  to  do  so  as  the  London  people,  and  so  they  followed 
their  example.  The  work  that  had  been  done  in  the  Society  had 
been  reported,  month  after  month  ever  since  very  early  times,  in 
the  Edinburgh  Medical  Journal.  A  small  pamphlet  was  published 
containing  some  of  the  proceedings  of  the  Society  in  the  year  1848. 
But  it  was  not  until  1870  that  the  Society  adopted  a  regular, 
systematic  method  of  publishing  its  Transactions.  The  first  volume 
was  published  in  that  year,  and  it  was  due  to  the  energy  of  Dr 
Peel  Eitchie,  who  was  at  that  time  Secretary.  It  was  followed 
afterwards  by  several  volumes,  each  embracing  all  the  work  that 


1889.]  THE   EDINBURGH   OBSTETRICAL   SOCIETY.  867 

had  been  done  during  two  or  three  years.     For  the  last  ten  years 
the  Society  had  published  an  annual  volume,  which  had  in  a  large 
degree  tended  to  the  increase  in  numbers  which  had  taken  place  of 
late  years.    These  members,  he  might  mention,  were  spread,  not  only 
over  Scotland,  but  over  England,  and  also  they  had  members  in 
the  Colonies  who  subscribed  to  the  Society  for  the  purpose  of 
receiving  its  Transactions.     In  speaking  of  the  work  which  this 
Society  had  done  he  felt  a  great  difficulty,  because  he  could  not  in  a 
meeting  like  the  present  do  anything  like  recapitulate  the  various 
papers  that  had  been  read  before  the    Society,  or  the  various 
authors  who  had  contributed  to  their  volumes.     He  would  only 
say,  that  almost  every  subject,  he  supposed,  which  was  dealt  with  in 
the  science  or  practice  of  obstetrics  and  of  gynsecology  had  been 
thrashed  out  again  and  again  in  the  Society's  meetings.     Every 
fresh  paper  upon  any  of  the  subjects  had  thrown  some  fresh  light 
upon  it,  and  gradually,  he  thought,  the  Society  had  advanced  with 
the  times,  and  they  had  themselves  advanced  in  every  way, — in 
the  character  of  their  papers  and  in  the  quality  of  them.     He  had 
only  to  remind  them  that  there  were  read  before   the  Society 
many  of  the  most  important  papers  which  were  written  by  Sir 
James  Simpson.     Some  of  his  earliest  publications  on  the  subject 
of  chloroform  and  of  ether  in  their  application  to  normal  and 
abnormal  parturition,  and  many  of  the  other  papers,  which  his 
original  genius  was  always  pouring  forth  with  very  great  frequency, 
were  read  before  the  Society,  all  of  which  were  worthy  of  the 
great  respect  they  received,  and  many  of  tliem  were  the  accepted 
doctrine  of  the  present  day.     There  were  numerous  papers  by  Dr 
Matthews   Duncan — among  the    most   valuable   that   had   been 
presented  to  them,  exhibiting,  as  they  did,  all  his  well-known  char- 
acteristics of  accui-acy  and  force  of  statement,  with  wide  knowledge 
of  the  subject  with  which  he  was  dealing,  both  in  its  scientific  and 
practical  aspects.    They  had  endless  papers  by  Dr  Keiller  on  every 
subject  which  could  well  be  written  upon.     The  records  of  the 
Society  were,  he  thought,  fuller  of  the  name  of  Dr  Keiller  than  any 
one  else  who  was  ever  connected  with  the  Society,  except,  perhaps. 
Sir  J.  Simpson.     When  he  came  down  to  later  days,  the  name  of 
Prof.  Alexander  Simpson  stood  well  to  the  fore  amongst  those 
who  had  done  good  work  for  the  Society.     The  Society  had  also 
many  of  the  papers  of  the  late  Angus  Macdonald,  well  known  for 
his  clear  headedness  and  very  great  ability.     His  paper  on  the 
"  Diseases  of  the  Heart  in  connexion  with  Pregnancy  and  Parturi- 
tion "  would  always  stand  as  a  monument  to  his  industry  and  know- 
ledge.    The  Society  in  its  earlier  times  had  a  most  valuable  paper 
on  the  "  Anatomical  Eelations  between  the  Bloodvessels  of  the  Foetus 
and  the  Mother  in  the  Placenta"  by  Dr  John  Eeid.    They  had  also  a 
great  paper  on  the  "Anatomy  of  the  Placenta"  by  Sir  William  Turner. 
They  had  also  a  number  of  papers  of  great  excellence  on  Anatomy, 
Physiology,  and  Pathology  by  Drs  Hart,  Barbour,  Croom,  and  a 


868  MEDICAL   NEWS.  [MARCH 

great  many  others,  and  he  (the  President)  might  go  on  all  the 
evening  mentioning  papers  which  he  deemed  important.  He 
thought,  however,  he  had  on  this  occasion  mentioned  enough.  He 
found,  on  looking  through  the  records  of  the  Society,  that  as  time 
wore  on  the  Society  followed  the  general  bent  of  medicine  and 
science  generally,  in  the  fact  that  conversations  took  a  less  part, 
and  papers  a  more  prominent  one  in  the  proceedings,  and  that  the 
papers  dealt  not  so  much  with  the  subjects  from  a  practical  and 
everyday  life  point  of  view  as  in  a  wider  and  more  general  form. 
They  dealt  more  with  the  algebra  and  less  with  the  arithmetic  of 
obstetrics.  They  had  an  abundance  of  papers  dealing  with  the 
supplementary  branches  which  lead  up  to  the  practice  of  Midwifery. 
They  had,  as  he  had  already  stated,  papers  on  Anatomy  and 
Physiology,  papers  on  Pathology,  microscopic  and  general,  and 
papers  on  /Etiology.  They  had  also  papers  on  the  prevention  of 
diseases.  They  had  statistics  from  the  Maternity  Hospital  and 
from  the  records  of  private  practice,  and  a  superabundance  of 
papers  on  the  surgery  of  this  branch  of  science.  Gynecology  had 
taken  a  decided  turn  from  being  what  it  was,  belonging  as  it  did 
half  to  medicine  and  half  to  surgery ;  it  had  now  passed  very 
largely  into  the  power  of  the  surgeons.  They  were  strong,  and  they 
had  the  knife  in  their  hands,  and  they  put  the  knife  firmly  into 
this  branch  of  the  science,  and  they  had  done  a  great  work.  The 
Society  also  varied  its  work  by  one  or  two  discussions  of  public 
interest.  A  good  many  years  ago — about  twenty-five  or  so — the 
Society  signed,  after  a  very  full  discussion,  and  sent  to  the  Town 
Council  a  note  suggesting  that  they  should  draw  up  a  Bill  on  the 
question  of  the  registration  of  vaccination.  Vaccination  was  then 
compulsory,  but  the  registration  of  it  was  not,  and  so  the  Society 
thought  the  Town  Council  should  draw  up  a  Bill  making  the 
registration  compulsory.  This  was  done,  and  it  is  now  passed  into 
law.  The  Society  had  also  a  great  deal  to  do  with  the  foundation 
of  the  new  Maternity  Hospital.  Of  course  any  suggestion  regard- 
ing an  hospital  of  that  kind  had  great  weight  coming  from  a 
society  of  this  kind.  The  Hospital,  as  all  knew,  was  connected 
with  the  name  of  Sir  James  Simpson.  As  had  been  said,  "Science 
lays  a  great  many  eggs,  but  they  don't  all  hatch."  So  it  was  with 
this  Society ;  everything  they  did  was  not,  of  course,  successful. 
Some  of  the  curiosities  which  he,  the  President,  had  found  in  the 
records  would,  he  thought,  interest  all  present.  One  gentleman 
thought  all  the  women  ought  to  be  delivered  by  forceps ;  another 
was  of  opinion  that  Nature  had  made  a  mistake  in  bringing  the 
children  into  the  world  head  foremost,  and  would  have  us  turn 
them  all  and  deliver  by  the  feet.  They  had  also  a  case  very  fully 
and  accurately  reported  in  which  a  woman  bore  a  child  at  the  age 
of  62.  There  was  reported  at  one  of  the  earlier  meetings  by  Dr 
Beilby  a  remarkable  case  of  violent  uterine  contractions.  Before 
she  was  delivered  she  lost  66  oz.  of  blood,  she  took  650  drops  of 


1889.]  THE   EDIXBURGH   OBSTETRICAL   SOCIETY.  869 

laudanum  by  the  mouth  and  300  more  by  the  rectum,  and  then, 
having  been  delivered  so  far,  she  was  allowed  to  rest,  and  the 
placenta  was  removed  the  following  day,  after  she  had  been  bled 
again.  A  case  like  this  makes  us  doubtful  whether  to  admire 
most  the  courage  of  our  predecessors,  the  toughness  of  their 
patients,  or  the  good  fortune  we  enjoy  in  the  possession  of  other 
and  less  severe  means  of  combating  powerful  uterine  contractions. 
Among  the  other  curiosities  was  a  paper  by  Dr  E.  B.  Finlay,  now 
Q.C.  and  M.P.,  on  Ancient  Greek  Midwifery.  After  labour  came 
refreshment,  and  the  members  of  the  Society  were  not  altogether 
without  some  alleviation  of  their  toils.  They  had  frequently 
dinners, — fish  dinners  at  Newhaven  being  occasionally  spoken 
about.  The  following  minute  of  a  dinner  held  at  one  of  the  hotels 
here  appeared  in  the  records :  "  Several  preparations,  wet  and  dry, 
were  discussed,  members  expressing  their  opinions  freely  in  their 
favour.  Professor  Simpson  introduced  a  slightly  coloured,  highly 
effervescent  fluid,  which  was  considered  to  be  in  some  respects 
superior  to  chloroform,  and  depending  largely  for  its  effects  on  the 
evolution  of  carbonic  acid  gas."  Another  dinner  was  spoken  of  at 
which  they  agreed  only  to  pay  10s.  6d.  a  head,  and  for  this  they 
were  each  allowed  two  glasses  of  champagne.  The  President  said 
they  could  take  as  many  as  they  liked  here  to-night — as  many  as 
they  could  carry  away  with  them.  He  could,  in  conclusion,  only 
ask  the  gentlemen  present  to  join  him  in  the  hope,  that  as  the 
years  went  on  the  Society  might  increase  and  flourish  both  in  point 
of  material  prosperity  and  in  scientific  reputation,  and  that  when  the 
time  came  fifty  years  hence,  and  our  successors  met  in  this  place 
or  elsewhere  to  celebrate  its  centenary,  they  might  be  able  to  look 
back  upon  a  great  record  of  work  done;  that  what  they  now 
looked  upon  as  merely  possibilities  might  have  become  the 
realities  of  the  future,  and  that  their  great  profession  of  Medicine 
in  general,  and  Obstetrics  in  particular,  might  have  made  a 
great  many  strides  towards  reaching  that  goal  which  they  all 
looked  forward  to,  when  Medicine  should  take  its  place  as  one  of 
the  exact  sciences  ;  and  he  only  hoped  that  some  of  the  members 
present  might  be  spared  to  see  the  day. 

Dr  Smith  said,  with  regard  to  the  President's  remarks,  he  might 
mention  that,  although  the  President  did  not  allude  to  the  fact  of 
Lucina  having  been  delivered  without  pain,  that  was  one  circum- 
stance that  he  (Dr  Smith)  thought  he  might  have  alluded  to.  And 
another  circumstance  he  thought  the  President,  when  speaking  of 
Dr  Beilby,  might  have  alluded  to,  was  that  Dr  Beilby  was  the 
medical  man  who  brought  him  (Dr  Smith)  into  the  world. 

Professor  Simpson,  rising  to  propose  the  toast  of  the  "Lord  Provost, 
Magistrates,  and  Town  Council  of  Edinburgh,"  said  that  it  was  a 
toast  which  was  welcome  always,  and  it  was  a  very  great  pleasure  for 
him  to  propose  it.  In  a  company  of  medical  men  like  the  present, 
there  were  very  many  reasons  why  attention  should  be  paid  to  it. 


870  MEDICAL   NEWS.  [MARCH 

They  (the  doctors)  were  supposed  to  have  the  health  of  the  com- 
munity largely  at  their  disposal,  but  unless  they  were  backed  by  a 
health  officer,  who  had  at  his  back  to  aid  him  an  intelligent  Council, 
it  was  little  that  the  medical  men  could  do  to  reduce  the  mortality 
to  the  rate  to  which  it  had  been  brought  down  in  this  city  In 
any  company  where  literature  or  science  was  in  any  degree  repre- 
sented, the  Town  Council  must  be  held  in  very  great  respect,  as 
being  ready  to  recognise  what  is  good  for  the  city  that  they  rule. 
It  had  been  said  that  the  staple  produce  of  Edinburgh  was  education. 
And  the  Lord  Provosts  and  Magistrates  had  always  taken  a 
lively  interest  in  all  that  went  for  the  promotion  of  education  in 
their  midst, and  especially  in  connexion  with  this  Obstetrical  Society. 
It  was  always  a  pleasant  memory  to  him  the  thought  that  in  the 
long  years  that  they  held  possession  of  the  University  of  Edin- 
burgh, they  (the  Magistrates,  etc.)  wielded  it  for  its  good,  and 
especially  in  this  direction,  that  they  were  the  first  to  found  a 
chair  for  the  teaching  of  the  science  they  were  all  met  there  to-night 
to  talk  of.  It  was  in  this  month,  some  173  years  ago,  that  their 
Town  Council  had  before  them  various  subjects  in  regard  to  the 
University  of  Edinburgh,  but  they  might  regard  as  the  most  impor- 
tant subject  on  that  February  day  the  consideration  of  the  founding 
of  a  Chair  of  Midwifery.  They  set  themselves  to  the  task,  and 
appointed  to  the  office  a  practitioner  in  Leith ;  and  they  said  that 
they  gave  him  all  the  privileges  bestowed  on  any  Professor  of 
Midwifery  in  any  other  teaching  corporation  or  college,  but  they 
had  the  Scotch  shrewdness  to  say,  that  this  was  not  to  be  to 
the  detriment  of  the  community.  When  he  (Professor  Simpson) 
came  to  investigate  this  when  Sir  Alexander  Grant  was  writing 
the  history  of  the  University  of  Edinburgh,  to  his  (Professor 
Simpson's)  surprise  he  discovered  that  this  was  the  first  of  all  the 
chairs  of  Midwifery  that  had  been  founded  in  any  teaching  com- 
munity in  the  whole  world.  He  should  have  thought  that  there 
would  have  been  a  chair  of  Midwifery  in  some  of  the  famous  Italian 
universities,  or  at  least  he  should  have  supposed  there  would  have 
been  at  Strasburg,  the  seat  of  the  foundation  of  the  printing  press, 
a  professor  of  Obstetrics.  It  was  not,  however,  till  two  years  later 
that  the  University  at  Strasburg  had  a  professor  of  Obstetrics,  and 
here  even  they  had  not  a  professor  wholly  set  apart  for  the  subject 
of  Midwifery.  He  might  be  professor  of  Medicine,  or  he  might  be 
professor  of  Surgery,  or,  as  at  Amsterdam,  Ruysch  was  in  his  time 
the  teacher  of  Midwifery,  So  Palfyn,  who  was  the  inventor  of 
the  use  of  forceps,  was  demonstrator  of  Surgery  at  Ghent.  Edin- 
burgh had,  therefore,  the  honour  of  being  the  first  University  to 
have  a  teacher  set  apart  wholly  for  the  purpose  of  instructing  in 
this  most  important  part  of  the  science  of  medicine,  without  which 
^le  occupation  of  all  the  others  would  be  gone.  In  connexion 
with  this  Society  the  President  had  already  stated  that  for  a  length 
of  time  one  of  the  Professors  of  Midwifery  sat  in  the  chair  of  the 


1889.]  THE   EDINBURGH  OBSTETRICAL   SOCIETY.  871 

Society,  and  he  saw  that  for  twenty-four  out  of  the  forty-nine  years 
of  the  existence  of  the  Society,  Joseph  Gibson's  successors  had 
been  connected  with  this  Society.     So  there  had  always  been  a 
connexion  between  the  Town  Council  of  Edinburgh  and  the  Edin- 
burgh Obstetrical  Society ;   but,  further,  they  had  an   important 
connexion    with    obstetrics     and    with    medicine    generally    in 
connexion  with  the  Royal  Infirmary  of  Edinburgh.     When,  in 
1791,   their   Professor   of   Midwifery   set   himself   to   found   the 
Maternity  Hospital  for  the  benefit  of  his  students  and  for  the 
training  of  nurses,  it  was  to  the  Town  Council  that  he  applied  for 
help.     It  was  with  their  aid  that  the  Maternity  was  founded,  and 
the  Lord  Provost  was  the  first  President  of  the  Lying-in  Institution. 
The  Lord  Provosts  had  continued  to  take  an  intelligent  interest  in 
the  progress  of  that  great  and  very  useful  institution.    So  he  thought 
he  had  said  enough  to  induce  the  gentlemen  present  to  drink  the 
toast  to  their  Lord  Provost,  Magistrates,  and  Town  Council  of 
Edinburgh ;  and  he  had  pleasure  in  coupling  with  it  the  name  of 
Lord  Provost  Boyd,  who  had  so  generously  come  and  graced  the 
table  with  his  presence,  and   he   hoped   that  the  Lord  Provost 
would  be  spared  in  good  health  and  have  a  long  and  glorious  reign. 
Lord  Provost  Boyd,  replying  to  the  toast,  said  that  he  had  great 
pleasure,  on  behalf  of  the  Magistrates  and  Town  Council,  in  reply- 
ing to  the  toast  which  they  all  had  so  kindly  received,  and  which 
had  been  given  in  so  flattering  terms  by  Professor  Simpson.    It  was 
always  a  pleasant  thing,  he  said,  to  the  Town  Council  to  meet  with 
the  approval  of  their  fellow-citizens ;  more  especially  was  it  agreeable 
to  hear  approval  from  an  assembly  like  the  present,  composed  of  so 
many  able  learned  men.     Professor  Simpson  had  referred  to  the 
long  connexion  that  had  existed  between  the  Town  Council  and 
the  University — a  connexion,  he  might  say,  honourable  to  both 
parties.     For  250  years  the  Town  Council  had  the  entire  manage- 
ment of  the  University.     It  grew  from  a  very  humble  beginning 
to  be  what  it  was  at  the  present  day — a  most  important  educational 
school.     He  was  not  there  to  quarrel  with  the  change  of  circum- 
stances  which   had  taken  place.     Times  change,  and  they  must 
change  with  them.     But  he  thought  they  might  say  for  the  Univer- 
sity, and  specially  for  the  Medical  Faculty  in  particular,  that  they 
had  rendered  them  a  service  (quite  equivalent  to  the  services  they 
had  rendered  them)  in  their  enterprise  in  making   the  Medical 
School  one  of  the  most  important,  if  not  the  most  important,  in  the 
world.     Of  course,  it  is  always  a  great  object  to  the  Town  Council  of 
Edinburgh  to  do  everything  to  promote  the  cause  of  education  in 
Edinburgh.      They  depended  largely  upon  education  as  their  staple 
industry,  and  the  Medical  School  of  Edinburgh  had  brought  them 
a  large  number  of  students  who,  but  for  the  fame  of  the  University 
in  that  respect,  would  have  gone  elsewhere.    They  were  indebted  also 
to  the  Medical  Faculty  in  Edinburgh  for  keeping  them  up  to  their 
duty  in  regard  to  sanitary  matters.     They  had  been  anxious  that 


872  MEDICAL   NEWS.  [MARCH 

Edinburgh  should  be  not  only  a  beautiful  city,  but  that  it  should 
also  be  a  healthy  city,  and  he  thought  they  had  done  really  all  that 
they  could  do  up  to  that  point.  He  was  quite  free  to  admit  that 
there  might  be  much  more  to  be  done  in  that  respect.  He  thought 
that  was  likely,  but  he  was  quite  sure  that  the  Medical  Faculty  in 
that  respect  would  keep  them  well  informed  as  to  their  duty,  and 
they  would  also  see  that  they  did  it.  Another  great  benefit 
they  enjoyed  at  the  hands  of  the  Medical  Faculty  was  in  the 
services  they  rendered  to  the  benevolent  institutions  of  Edin- 
burgh. There  was  nothing  struck  him  more  since  he  received 
the  office  of  Lord  Provost  than  the  great  devotion  and  dis- 
interested self-denial  on  the  part  of  the  medical  men  in  Edin- 
burgh in  giving  up  their  time  and  their  skill  to  the  services  of 
the  poor  of  the  city.  He  had  had  occasion  to  be  present  at  a  great 
many  charities  that  he  knew  little  or  nothing  about  before  he 
became  Lord  Provost,  and  he  thought  that  which  struck  him  most 
was  the  amount  of  service  which  was  given  by  the  medical  men  of 
Edinburgh — which  was  given  freely  and  gratuitously.  Like  the  old 
man  they  had  heard  of  in  Dr  Smith's  song,  one  might  say  a  great  deal 
of  this  as  being  a  benefit  to  the  Medical  Faculty, — it  increased 
their  skill  and  experience, — but  there  was  still  an  immense  amount 
of  it  which  was  given  which  could  not  be  accounted  for  in  that  way, 
and  which  was  given  from  the  best  motives  and  from  a  desire  to  be 
useful  to  the  community.  He  had  only  again  to  thank  them  in 
the  name  of  the  Town  Council  for  their  kindness. 

Mr  Lawson  Tait,  proposing  the  toast  of  the  "  Universities  of 
Scotland,"  said  that  when  he  was  invited  by  the  President  to  the 
Jubilee  Meeting  of  the  Edinburgh  Obstetrical  Society,  he  accepted 
the  invitation  with  much  pleasure,  and  he  was  determined  at  all 
costs  to  be  present  for  very  many  reasons,  and  the  chief  of  those 
was  that  it  was  the  earliest  medical  society  with  which  he  had 
any  kind  of  personal  relation.  For  he  could  very  well  remember 
when  a  pupil  at  the  Old  Town  Dispensary,  being  favoured  by  the 
kindness  of  a  man  whose  name  does  not  stand  high  in  the  annals 
of  his  profession,  but  a  man  who  was  kindness  itself.  He  meant 
Dr  David  Gordon.  He  gave  him  an  introduction,  and  with  great 
earnestness  he  used  to  wander  down  to  the  New  Dispensary  when 
he  belonged  to  the  Old,  and  there  he  saw  three  or  four  gathered 
together  in  the  small  upper  room,  and  this  was  what  the  Society 
grew  from.  Many  was  the  good  lesson  which  he  can  remember 
having  learnt  there,  and  therefore  he  came  here  as  a  matter  of  duty. 
And  when  it  was  asked  by  the  Secretary  that  he  should  propose  the 
toast  of  the  Universities  of  Scotland,  he  felt  doubly  bound  to  be 
present,  for  the  selection  to  him  was  an  honour,  and  the  recollec- 
tions were  none  but  very  pleasant.  To  speak  upon  such  a  toast 
was  an  easy  matter.  He  had  only  to  read  up  the  history  of  each 
university  by  getting  hold  of  their  calendars.  He  found  that  the 
oldest  University  was  St  Andrews.    It  did  not  seem,  he  thought,  to 


1889.]  THE   EDINBURGH   OBSTETRICAL   SOCIETY.  873 

have  any  connexion  with  obstetrics,  except  the  remembrance,  it 
may  be,  that  it  superintended,  after  many  serious  pains,  the  birth 
of  the  Scottish  Reformation.  The  University  of  Aberdeen,  repre- 
sented by  his  late  teacher  Dr  Stephenson,  who  was  one  of  his 
earliest  dispensary  instructors,  comes  next,  and  it  contains  a  record 
of  praise  to  which  he  did  not  need  to  allude.  It  was  recorded  by 
Dugald  Dalgetty.  For  Glasgow  one  could  speak  in  terms  of  praise. 
Prof.  Leishman  had  contributed  greatly  to  obstetrical  literature.  To 
go  back,  they  all  remembered  Burns,  who  was  one  of  the  advance 
guard  of  abdominal  surgery.  He  advised  them  how  to  deal  with 
ectopic  gestations,  and  it  was  only  now,  after  neglecting  his  teaching 
for  nearly  one  hundred  years,  that  they  had  come  to  follow  out  what 
he  then  indicated.  When  he  came  to  his  own  University  a  rush 
of  thoughts  impeded  utterance  entirely,  and  the  faces  round  him 
now  spoke  for  that.  At  the  other  end  of  the  table  there  was  a  man 
for  whom  he  had  the  utmost  reverence — the  man  who  taught 
him  all  the  exact  observations  he  knew,  who  was  then  the 
Demonstrator,  and  was  now  their  revered  Professor  of  Anatomy. 
Then  there  was  the  President  of  the  College  of  Surgeons,  '\\'ho  was 
his  instructor  in  Surgery.  He  was  then  House-Surgeon,  and  he, 
Mr  Lawson  Tait,  was  a  pupil,  but  he  often  thought  of  the  lessons 
he  learnt  from  Joe  Bell.  Of  the  President  he  could  not  speak, 
except  that  he  came  from  a  good  Midland  stock  held  in  the 
highest  respect.  Of  his  friend  on  the  left  he  would  say  this  much. 
He  brouglit  him,  Mr  Tait,  early  in  his  life  into  association  with 
one  of  the  noblest  characters  he  had  ever  known, — a  man  whose 
name  was  not  well  known,  and  therefore  he  would  not  mention  him 
— a  man  who  lived  a  most  spotless  unknown  life  in  a  remote  village. 
With  his  friend  on  the  right  he  had  an  obstetrical  connexion. 
He  delivered  him  of  his  dental  pains,  and  (the  joke  was  his  own)  he, 
Dr  Smith,  said  it  was  a  forceps  case.  On  his  left  there  was  his 
first  instructor  in  all  the  art  he  ever  practised.  To  go  down  the 
table  he  might  magnify  the  list.  He  would  only  mention  Dr 
Keiller's  name.  No  words  of  his  could  express  the  obligation  that 
he  owes  to  him.  Then  there  was  his  late  master,  Dr  Littlejohn. 
He  had  already  received  to-night  his  meed  of  praise,  but  he,  Dr 
Littlejohn,  knew  how  highly  he  would  word  it  if  he  had  his  testi- 
monial to  write.  Of  the  University  of  Edinburgh  he  could  not  speak 
in  terms  too  high.  It  was  a  great  thing  to  him  that  he  was  brought 
up  in  it.  And  the  changes  which  had  been  effected  in  its  history 
within  the  last  twenty-five  years  since  he  left  it  were  associated  with 
feelings  of  mixed  pleasure  and  sadness.  Pleasure  that  its  usefulness 
had  been  so  extended — that  its  success  had  been  so  bright ;  sadness 
that  those  changes  had  been  so  numerous — that  there  existed  not 
now  a  man  who  held  a  chair  when  he  was  a  student.  Every  chair 
was  then  occupied  by  a  man  who  was  the  head  of  his  profession. 
Now  it  was  the  same.  There  was  no  occupant  of  a  chair  in  the  whole 
University  who  could  not  be  quoted  as  facile  princeps,  certainly  in 

EDINBURGH   MED.    JOURN.,   VOL.   XXXIV. — NO.    IX.  5  8 


874  MEDICAL   NEWS.  [MARCH 

the  first  rank  of  professional  life.  That  the  success  had  been  so  great 
was  only  the  necessary  consequence  of  the  generation  that  had  gone 
and  the  one  that  had  come.  He  did  not  think  that  in  the  whole 
ranks  of  the  profession  of  Medicine  anyone  could  claim  a  higher 
honour  than  to  be  trained  there.  How  closely  the  art  of  Obstetrics 
had  run  with  the  progress  of  the  University  of  Edinburgh ! 
He  need  not  tell  them  that  the  name  the  present  professor  bore  was 
largely  answerable  for  that.  For  there  was  not  anyone  of  them  who 
occupied  a  position  outside  that  University  in  the  art  of  Obstetrics, 
or  of  the  newly  knov^^n  science  of  Gynaecology,  who  did  not  owe, 
directly  or  indirectly,  almost  all  they  had  to  his,  Dr  Simpson's, 
predecessor.  The  glory  of  that  name  had  yet  to  be  fully  under- 
stood in  the  good  it  had  done  this  century  and  education.  For  not 
only  did  he  direct  us  in  lines  which  he  then  knew,  but  he  pro- 
phesied for  us,  and  guided  us  in  lines  which  he  did  not  know,  but 
which  his  genius  pointed  out.  It  will  be  long,  perhaps  it  never 
will  be,  that  the  influence  of  his  teaching  will  be  lost.  The 
recollection  of  those  old  days  impeded  one's  utterance  and  enfeebled 
one's  speech,  for  it  was  part  of  one's  life  when  one  recalled  back  the 
old  days  of  the  University.  If  there  was  one  toast  which  he  liked 
more  than  another  it  was  the  success  of  the  Scottish  Universities,  par- 
ticularly of  the  University  in  which  he  was  trained.  He  therefore 
proposed  the  health  of  the  Scottish  Universities,  more  particularly 
ihat  of  Edinburgh,  and  he  coupled  it  with  the  names  of  the  Dean 
of  the  Faculty,  Professor  Eraser,  and  Professor  Stephenson  of 
Aberdeen.  The  Dean  of  the  Faculty  was  a  very  different  person 
in  his  days  from  the  present  one.  The  students  of  the  present 
day  are  not  afraid  of  the  Dean.  In  their  days  it  was  a  serious 
question  as  to  what  was  to  happen  when  the  Dean  wanted  to  see 
any  of  them.  He  remembered  being  present  at  an  interview  with 
the  Dean  of  the  Faculty,  whose  name  he  would  not  mention.  He 
went  with  a  gentleman  who  had  served  in  the  Indian  Service,  and 
who,  under  the  old  regulations  of  '59,  desired  to  become  a  graduate. 
He  bore  evidence  of  many  years  in  tropical  climes.  He  had  lost  all 
the  hair  off  his  head,  and  had  his  head  covered  by  an  artificial  sub- 
stitute. He  could  not  present  to  the  Dean  a  certificate  of  his  age, 
and  he  assured  the  Dean  that  he  was  over  21.  He  said,  "  I  assure 
you.  Professor,  my  appearance  is  sufficient  to  indicate  that  I  am  21 
years  of  age."  "  Ah  ! "  said  the  Professor,  "  but  appearances  are 
deceptive."  Now,  he  believed,  the  present  Dean  was  kinder  than 
his  predecessors,  and  he  hoped  that  they  would  all  long  flourish 
under  the  present  regime. 

Professor  T.  R.  Fraser,  the  Dean  of  the  Medical  Faculty,  in 
rising  to  reply  to  the  toast  on  behalf  of  the  University  of  Edin- 
burgh, said  he  found  himself  in  a  position  of  some  difficulty,  in  so 
far,  as  he  thought,  all  the  company  had  expected  that  this 
toast  would  have  been  adequately  acknowledged  by  our  revered 
Principal  of  the  University  of  Edinburgh.    They  all  regretted  greatly 


1889.]  THE   EDINBUKGH   OBSTETRICAL   SOCIETY.  875 

that  he  was  unable  to  be  present  that  night,  and  he  felt  sure  that  if  he 
had  been  present  that  night,  having  recollections  of  all  the  tercen- 
tenary celebrations  in  connexion  with  the  University  of  Edin- 
burgh, he  would  have  been  the  first  to  have  congratulated  this 
Society  most  heartily  upon  its  fiftieth  anniversary,  and  to  have 
hoped  that  in  the  following  fifty  years,  when  the  centenary  cele- 
bration had  been  reached,  the  progress  of  this  Society  would  have 
been  as  great  as  the  University  of  Edinburgh  and  of  the  other  univer- 
sities of  Scotland  in  the  corresponding  period  of  fifty  years.  He  felt 
sure  tliat  if  he  had  been  able  to  be  present  he  would  have  referred 
with  very  great  gratification  to  the  circumstance  that,  in  so  far 
as  the  Medical  Faculty  of  the  University  was  concerned,  there  was 
certainly  no  greater  glory  to  be  attached  to  that  Faculty  than  the 
glory  which  proceeds  from  the  work  which  had  been  done  by  the 
professors  and  practitioners  in  Obstetrics  who  had  proceeded  from 
the  University  of  Edinburgh.  He  felt  sure  he  would  have  con- 
gratulated the  Society  not  only  on  the  fame  which  had  been 
obtained  by  former  members  of  the  University,  but  likewise  on 
the  fame  which  was  being  increased  by  those  who  had  been  trained 
in  it,  and  who  are  still  able  to  continue  to  do  the  work  which  they 
commenced  in  that  University.  He  would  have  referred  to  the 
remarkable  prominence  its  students  have  attained  in  London,  in 
the  various  cities  of  England,  in  the  midland  counties  of  England, 
in  Newcastle,  and  not  less,  he  thought,  in  Birmingham  also ;  and 
he  thought  he  would  have  been  able  to  prophesy  that  that  very 
gratifying  list  of  names  was  not  likely  to  fail  the  University,  because 
it  was  a  remarkable  circumstance,  that  owing,  he  did  not  know  to 
what  cause,  it  might  be  to  the  necessary  publicity  of  this  branch  of 
Medicine,  it  might  be  also  to  the  great  success  and  wealth  which 
attached  to  it,  but  this  he  was  able  to  say,  that  among  the  many 
benefactions  which  the  University  had  received,  there  had  been 
none  more  numerous  in  connexion  with  any  part  of  Medicine  than 
those  which  had  been  received  for  obstetrical  work,  for  the  purpose 
of  encouraging  and  of  giving  an  opportunity  to  any  man  to 
prosecute  Obstetrics ;  and  he  anticipated  that  there  would  be  no 
falling  off  in  that  very  important  cause  of  glory  to  the  University 
of  Edinburgh — the  prosecution  of  obstetrical  science.  That  Univer- 
sity, as  well  as  all  the  other  universities  of  the  country,  were  at  the 
present  moment  undoubtedly  in  a  state  of  uncertainty.  They 
expected  that  there  would  be  a  number  of  changes  made  in  a  short 
time  in  connexion  with  the  arrangements  in  the  University.  They 
had  become,  in  a  sense,  accustomed  to  the  idea  that  these  changes 
were  inevitable,  and  he  thought  he  might  say  for  the  universities  in 
general,  that  they  all  sincerely  hoped  that  these  changes  would  be 
accomplished  successfully  and  peaceably.  They  thought  that  the 
usefulness  of  the^universities  would  be  increased  if  the  condition  of 
uncertainty  was  removed  as  rapidly  as  possible,  and  if  this  Bill, 
which  had  been  hanging  over  them  for  more  than  a  decade,  were 


876  MEDICAL  NEWS.  [^ARCH 

passed  into  law  in  the  coming  session,  and  he  hoped  that  whatever 
changes  were  accomplished,  would  really  do  good.  In  the  first 
place,  he  said,  nothing  would  be  done  to  Obstetrics,  which  had  been 
extremely  successful,  and  he  would  say  that  nothing  would  be  done  in 
any  respect  to  injure  the  universities  in  all  the  other  departments. 
He  had,  on  behalf  of  the  University,  to  thank  them  very  much. 

Professor  Stephenson  of  Aberdeen  said,  as  an  old  member  of  this 
Society, — and  as  he  looked  round  the  table,  he  was  sorry  to  say  that 
he  was  the  fifth  oldest  member  present, — he  rose  to  reply  to  the 
toast.  As  an  old  member  he  worked  along  with  his  fellow  Professor 
of  Obstetrics  in  that  little  upper  room,  in  those  glorious,  those  useful 
days,  when  the  business  was  conducted  in  a  somewhat  more  con- 
versational style,  when  they  discussed  and  got  that  valuable  informa- 
tion Mr  Tait  had  told  them  of.  When  he  received  the  invitation  to 
be  present  there  that  night  he  felt  it,  like  the  proposer  of  the  toast, 
his  duty,  and  nothing  would  have  prevented  him  enjoying  the 
pleasure.  It  was  not  only  a  pleasure  but  a  high  honour — an  honour 
which,  when  he  joined  the  Society,  he  could  hardly  have  aspired  to. 
He  said  they  were  all  aware  of  the  prayer  of  the  good  honest  man, 
who  asked  the  Lord  to  give  him  a  good  conceit  of  himself,  and  he 
thought  that  certainly  they,  as  Scotch  graduates  of  the  universities, 
had  good  cause  to  have  a  good  conceit  of  themselves.  There  was,  he 
said,  a  great  characteristic  in  connexion  with  Obstetrics  in  reference 
to  the  universities.  They,  the  Scottish  universities,  stood  on  a 
different  footing  from  all  the  other  universities  or  schools  in  the 
kingdom.  They  had  the  great  advantage  of  having  a  fuller 
number  of  months  devoted  to  it — six  months,  or  now  fully  five 
months,  instead  of  three  months ;  and  this  characteristic  of  the 
Scotch  universities,  he  should  hope,  would  never  be  touched,  but 
that  they  should  be  able,  not  to  lower  themselves  to  the  standard  of 
the  English  teaching,  but  rather  try  to  raise  the  English  teaching 
to  their  standard.  Allusion  had  been  made  already  that  evening  to 
the  great  advances  in  Obstetrics,  and  specially  to  the  wonderful 
effects  which  antiseptics  had  had  upon  the  practice.  He  thought 
they  might  rejoice  that  the  antiseptic  treatment  had  its  origin  in 
Scotland.  He  had  already  referred  to  the  increased  length  of 
their  period  of  teaching.  He  was  anxious  to  point  out  another 
relation  which  he  thought  there  was  some  danger  in.  He 
meant  the  anxiety  which  the  General  Medical  Council  and  those 
in  England  had  that  their  obstetrical  training  was  so  exceedingly 
important,  that  they  should  increase  the  number  of  midwifery 
cases  which  students  require.  He  thought  that  was  a  great 
mistake  indeed  for  the  Legislature  to  insist  upon  increasing  the 
modest  number  of  cases  that  the  Scotch  universities  had  been 
contented  with.  He  thought  it  was  not  by  asking  the  students  to 
attend  midwifery  cases  that  they  would  increase  their  knowledge. 
In  proportion,  he  thought,  as  they  increased  these  opportunities 
they  forced  them  to  take  out  their  cases  before  they  had  listened  to  a 


188».]  THE  EDINBURGH   OBSTETRICAL   SOCIETY.  877 

single  lecture,  and  before  they  had  learned  more  than  they  could 
get  out  of  S Wayne's  Aphorisms.  He  did  not  think  that  was  a  proper 
position  for  a  man  to  come  to  his  cases  in.  Increase  their 
number,  and  then  they  should  be  in  somewhat  the  position  of  the 
midwives  who  could  always  boast  that  they  had  had  their  hundred 
cases.  That  was  not  the  way  to  raise  Obstetrics.  It  was  by 
raising  their  teaching,  and  it  was  in  that  respect  that  the  advance  in 
Midwifery  had  been  made,  it  had  not  been  made  by  the  number  of 
cases.  He  rejoiced  that  his  old  Society,  the  Obstetrical  Society,  was 
leading  well  in  the  van  of  the  profession,  and  that  there  was  excellent 
work  being  done  by  the  members.  He  rejoiced  to  receive  their 
Transactions.  He  watched  their  work,  and  the  work  that  was  being 
done  was  work  which  could  not  be  surpassed  in  any  other  country, 
and  which  was  not  equalled  by  many.  Such  work  was  an  honour  to 
the  Society.  He  had  to  thank  them  for  remembering  the  Aberdeen 
University. 

Dr  Halliday  Groom,  rising  to  propose  the  toast  of  the  "  Medical 
Corporations  of  Scotland,"  said  the  toast  which  had  been  entrusted 
to  him  was  the  toast  of  the  Medical  Corporations  of  Scotland.  He 
thought  it  would  be  out  of  place  if  he  were  to  endeavour  to  trace 
the  history  of  the  various  bodies  included  in  the  toast,  because  he 
took  it  that  it  was  familiar  to  all  present  as  household  words.  He 
felt  sure  they  would  all  agree  with  him  that  those  institutions,  if  they 
considered  their  position  from  any  point  of  view,  either  in  that  of 
medical  reform  or  merely  as  great  colleges  which  gave  forth  enormous 
numbers  of  licenseships,  and  had  done  an  enormous  amount  of 
good ;  or,  if  they  considered  them  as  institutions  conserving  the 
best  interests  of  the  profession,  they  deserved  well  both  of  the 
profession  and  of  the  country.  He  did  not  think  it  necessary  to 
give  them  any  lengthened  account  of  those  institutions.  He 
fancied  when  any  one  looked  back  on  their  history  it  was  one  of 
prosperity.  The  success  of  those  institutions  had,  to  some  extent, 
brought  about  a  certain  amount  of  jealousy.  It  was  impossible  it 
could  do  anything  else.  It  was  not  his  intention  to  enter  into 
anything  like  medical  politics.  He  would  only  say  that  there 
were  schemes  afloat  which  would  reduce  their  revenues,  steal  their 
prestige,  and  diminish  the  number  of  their  licentiates.  He,  how- 
ever, did  not  think  that  was  at  all  likely  to  take  place.  This  he 
would  say,  that  when  those  schemes  were  afloat,  he  felt  sure  no 
society  would  do  more  to  frustrate  them  than  the  Obstetrical 
Society  of  Edinburgh.  These  colleges  had  great  traditions — 
traditions  of  which  all  were  proud,  and  they  had  done  work  of 
which  they  had  good  reason  to  be  proud.  If  they  looked  at  the 
palatial  residences  in  which  they  resided,  at  the  great  museums 
they  had  collected,  at  the  libraries  they  had  amassed,  and  at 
all  the  other  good  works  they  had  done,  he  thought  they  would 
all  agree  with  him  that  they  had  good  reason  to  be  proud  of  them. 
But  if  they  had  reason  to  be  proud  of  the  past,  they  had  no  reason 


878  MEDICAL   NEWS.  [MARCH 

to  fear  the  future.  He  thought  the  future  would  be  more  success- 
ful than  the  past ;  and  he  thought,  so  long  as  these  colleges  were 
presided  over  as  at  present,  they  had  no  reason  to  be  afraid  of 
their  future.  He  had,  therefore,  much  pleasure  in  proposing  this 
toast  of  the  Medical  Corporations  of  Scotland,  and  of  coupling 
with  it  the  names  of  the  President  of  the  Eoyal  College  of 
Physicians,  Dr  Peel  Ritchie,  and  of  the  President  of  the  Eoyal 
College  of  Surgeons,  Dr  Joseph  Bell. 

Dr  Peel  Ritchie,  President  of  the  Royal  College  of  Physicians, 
said  it  was  with  great  pleasure  that  he  rose  to  return  thanks.  He 
said  it  had  been  to  him  a  great  pleasure  to  be  present  at  that 
meeting.  The  Society  was  closely  connected  with  the  College  of 
Physicians.  It  was,  he  said,  a  singular  fact  that,  although  the 
College  of  Physicians  at  one  time  objected  to  any  of  its  Fellows 
practising  the  obstetrical  art,  as  enlightened  ideas  came  into  it 
they  removed  the  obstruction,  and  those  practising  Midwifery  were 
allowed  to  become  Fellows  of  the  College.  It  was  a  singular  fact 
that  of  the  18  Presidents  of  that  Society,  no  less  than  15  had 
been  Fellows  of  the  Royal  College  of  Physicians.  It  was  note- 
worthy that  amongst  the  earlier  members  of  the  Society  all  those 
who  now  remained  still  to  the  fore  were  also  Fellows  of  the  Royal 
College  of  Physicians.  It  certainly  spoke  well  for  the  longevity 
which  they  possessed  in  the  College,  and  showed  that  whilst  the  Col- 
lege went  on  flourishing  its  members  went  on  flourishing  also.  The 
College,  after  its  remarkable  past,  had  no  reason  to  fear  the  future. 
In  the  past  they  had  done  their  duty,  and  in  the  present  they  were 
endeavouring  to  do  their  duty  according  to  their  light.  He 
thought  that  continued  prosperity  would  follow  the  course  which 
they  were  pursuing.  He  had  to  thank  them  for  the  honour  they 
had  done  to  the  College  of  Physicians. 

Dr  Joseph  Bell,  on  replying  to  the  toast  on  behalf  of  the  Royal 
College  of  Surgeons,  said,  his  friend  who  had  just  spoken  was 
trying,  he  thought,  to  make  out  that  the  physician  was  far  more 
connected  with  this  Society  than  the  College  of  Surgeons.  That  was 
a  mistake.  The  College  of  Surgeons  was  very  famous  in  obstetri- 
cians. When  he  pointed  to  the  fact  that  the  President  was  a  Fellow, 
Dr  Croom  was  also  a  Fellow,  and  Mr  Tait  was  also  a  Fellow,  who 
had  done  more  for  the  lengthening  the  life  and  relieving  the  suf- 
ferings of  women  than  any  other  single  man  in  this  country,  or  even 
in  the  world ;  when  he  mentioned  these,  he  was  not  at  a  loss, 
notwithstanding  what  Dr  Peel  Ritchie  might  say.  With  these  very 
few  remarks  he  had  much  pleasure  in  thanking  them  on  behalf  of 
the  Royal  College  of  Surgeons. 

Dr  Foulis,  rising  to  propose  the  toast  of  "  Kindred  Societies,"  said 
he  rose  with  pleasure  to  propose  the  toast  of  Kindred  Societies. 
When  he  first  saw  the  toast  of  Kindred  Societies  on  the  paper,  he 
asked  himself  what  societies  should  be  classed  under  the  name  of 
kindred.     A  few  moments'  consideration  convinced  him  that  all 


1889.]  THE   EDINBURGH   OBSTETRICAL   SOCIETY.  870 

scientific  societies  should  be  included.  All  scientific  societies 
which  were  bound  together  by  a  sincere  love  of  truth,  by  an  uncon- 
querable desire,  in  spite  of  all  opposition,  to  arrive  at  the  truth, 
would  link  tliat  society  under  the  title  of  kindred  society  to  the 
Obstetrical  Society  of  Edinburgh.  He  said  he  should  be  nearer 
the  truth  when  he  said,  that  all  those  societies  are  more  truly 
kindred  which  were  classified  under  the  term  biological,  or  those 
societies  which,  in  the  spirit  of  true  inquiry,  had  to  deal  with 
the  laws  of  health  and  disease.  He  had  much  pleasure,  therefore, 
in  proposing  the  toast  of  the  British  Gynaecological  Society,  coupled 
with  the  name  of  Mr  Lawson  Tait ;  the  Medico-Chirurgical  Society 
of  Edinburgh  and  Dr  John  Smith ;  the  Gynrecological  Society  of 
Glasgow  and  Dr  Nairnc ;  and  the  Royal  Medical  Society  and  Dr 
Harvey  Littlejohn. 

Mr  Lawson  Tait  said  he  had  much  pleasure  in  replying.  The 
British  Gynaecological  Society  was  an  offshoot  of  the  London  Obstet- 
rical Society.  It  was  a  child  born  in  great  trials,  but  still  he 
thought  its  career  had  not  been  devoid  of  usefulness.  They  were 
only  four  years  old,  and  they  were  as  mature  as  the  parent,  and 
quite  as  active  and  useful. 

Dr  Smith  said  he  had  much  pleasure  in  replying  for  the  Medico- 
Chirurgical  Society,  and  also  for  the  Harveian  Society  in  the 
absence  of  Dr  Gillespie.  He  did  not  expect  to  have  had  to  reply 
to  any  toast  whatever,  and  there  were  two  things  in  this  world 
which  a  man  was  never  prepared  for ;  these  were  twins.  Another 
thing  they  were  never  prepared  for  was  to  reply  to  a  toast  in  the 
manner  he  had  to  do. 

Dr  Stuart  Nairne,  rising  to  respond  to  the  toast  on  behalf  of 
the  Glasgow  Gynaecological  Society,  said  he  thanked  them  heartily 
for  the  way  they  had  received  the  toast.  He  felt  sure  when  he  went 
back  to  Glasgow  the  members  would  be  pleased.  They  in  Glasgow, 
being  the  west  of  Scotland,  look  towards  Edinburgh  as  the  source 
of  their  light.  The  Edinburgh  Obstetrical  Society  had  had  a  long 
career  before  the  Society  in  Glasgow  had  come  into  existence. 
They  were  only  in  existence  three  years,  and  they  could  hardly 
boast  that  they  had  escaped  all  the  dangers  of  early  life.  He  said 
the  Edinburgh  Society  was  indeed  a  bright  example  to  them. 

Dr  Harvey  Littlejoh7i,  on  behalf  of  the  Eoyal  Medical  Society, 
said  he  was  glad  to  have  this  opportunity  of  expressing  the  heartiest 
congratulations  to  this  Society  on  its  fiftieth  anniversary.  They  (his 
Society)  were  an  old  Society,  and  had  already  celebrated  three  such 
anniversaries.  He  hoped  the  Obstetrical  Society  would  also  live 
and  prosper,  and  when  the  time  came  celebrate  other  anniversaries  ; 
and  he  thought  if  the  Royal  Medical  Society  could  go  on  in  the  way 
which  they  had  done  previously  in  doing  their  utmost  according 
to  their  light  in  advancing  medical  knowledge,  and  also  in  sup- 
plying members,  and  he  hoped  useful  members,  to  the  Obstet- 
rical Society,  they  would  be  amply  satisfied. 


880     .  MEDICAL  NEWS.  [MARCH   1889. 

Dr  George  Paterson  said  he  had  been  requested  to  propose  a  toast 
which  he  felt  sure  would  meet  with  the  acceptance  of  every  member 
present.  It  fell  to  him,  he  said,  because  he  was  one  of  the  survivors 
of  the  foundation  of  this  Society.  He  said  it  was  an  old  story 
since  he  had  first  the  honour  of  acting  as  Secretary,  and  it  was,  he 
said,  certainly  astonishing  to  see  the  large  assembly  now  met  together 
as  members  of  the  Society.  He  thought  all  would  feel  that  this  had 
been  a  most  interesting  meeting,  and  that  the  interest  of  the  meet- 
ing was  greatly  due  to  the  address  they  had  received  from  the 
President,  and  he  had  much  pleasure  in  asking  the  members 
present  to  drink  the  toast  of  the  President. 

The  President,  rising,  in  reply  said  he  thanked  them  mostheartily 
for  the  kind  way  in  which  they  had  received  the  toast.  He  said  it 
was  an  honour  to  him  to  be  President  at  the  meeting,  and  the 
honour  was  increased,  he  said,  by  having  liis  toast  proposed  by  one 
of  its  oldest  members.  He  was  the  first  Secretary,  and  if  he  after- 
wards went  into  another  branch  and  succeeded,  it  was  none  the  less 
to  the  honour  of  the  Society  that  he  belonged  to  them  originally, 
and  that  he  had  survived  so  many  years  in  health,  and  he  hoped  in 
happiness  also.  It  only  remained  for  him  again  to  thank  them, 
and  ask  them  to  drink  to  "  Ploreat  Lucina." 


Royal  College  of  Physicians,  Edinburgh. — The  following  gentleman  passed  his 
final  examination  for  the  degree  in  Medicine  at  the  sittings  held  on  7th  February 
1889,  and  was  admitted  L.R.C.P.  Ed.: — Bartholomew  Langran,  Carlow. 


Obituary  notices  of  Dr  Bontheon  of  West  Linton,  and  of  Dr 
Alexander  James  Sinclair,  Edinburgh,  are  unavoidably  postponed 
till  our  next  number. 


IM.AI'K     I. 


Head. 


15 


1.  Lower  maxilla. 

2.  Upper  maxilla  and  roof  of  mouth,  not  completely  ossified. 

3.  Spongy  bone. 

4.  Solid  part  of  spongy  bone. 

5.  Part  of  superior  malar  bone — infra  orbital  plate. 

6.  Superior  orbital  pkae  ;ind  part  of  frontal  bone. 
7  Part  of  parietal  bone. 

8.  Baso-occipital  bone. 

9.  Part  of  parietal  bone. 

10.  Part  of  parietal  bone. 

11.  Spongy  bone  part. 

12.  Sphenoidal  bone. 

13.  Parts  of  spongy  bone. 

14.  Temporal  bone. 

15.  Parts  of  temporal  bone — aural  portions. 

16.  Parietal  bone. 

17.  Parietal  bone. 


J.    Stuart    Nairne. 


IT  L,r\.   1    tL        II. 


Body   and    Limb. 


13 


Bones— cervical,  immediately  below  liead 

Upper  part  of  body :   spine. 

Upper  part  of  body 

Spine. 

Pelvic  bone. 

Pelvic  bone. 

Femur. 


Epiphysis  of  tiljia 

Tibia. 

Scapula. 

Clavicle. 

12.  Ribs. 

13.  Sternum. 


ORIGINAL   COMMUNICATIONS. 

I.— DEKMATITIS  HERPETIFORMIS. 

By  T.  M'Call  Anderson,  M.D.,  Professor  of  Clinical  Medicine,  University 

of  Glasgow. 

Syn. — Dermatitis  pruriginosa  (White) ;  Dermatitis  multiformis 
(Piffard);  Tropho-neurotic  dermatitis  (Morrow);  Dermatite  poly- 
morphe  prurigineuse  chronique  a  pousles  siiccessives  (Brocq)  ;  Pem- 
phigus pruriginosus  (Chausit  and  Hardy). 

We  are  indebted  to  Duhring  for  the  first  accurate  description 
of  this  disease,  or  group  of  diseases,  and  for  the  name  which  it 
bears,  his  first  communication  on  the  subject  having  been  made  to 
the  American  Medical  Association  in  1884.' 

It  is  probably  not  so  rare  an  affection  as  some  suppose,  seeing 
that  it  is  apt  to  be  mistaken  for  pemphigus,  erythema  multiforme, 
eczema,  etc.  The  most  prominent  characters  of  the  disease  are 
these : — 

1.  It  has  a  great  tendency  to  be  polymorphous,  occurring  as  it 
does  in  various  forms,  which  run  into,  or  succeed  one  another, 
during  the  course  of  the  illness ;  the  lesions  being  erythematous, 
papular,  vesicular,  bullous,  or  pustular,  and  these  may  be  combined 
in  various  ways.  In  a  good  many  cases  the  mucous  membranes 
are  involved  as  well,  especially  that  of  the  mouth  and  pharynx. 

2.  It  appears  in  successive  crops  of  eruption  (generally  more  or 
less  in  groups  or  clusters)  at  irregular  intervals,  each  setting  in,  as 
a  rule,  with  some  fever  and  constitutional  disturbance. 

3.  It  is  accompanied,  and  often  preceded,  by  intense  irritation, 
burning,  or  smarting,  which  may  be  generalized,  or  limited  to  the 
seat  of  the  lesions. 

4.  It  may  attack  any  part  of  the  body,  but  seems  to  have  a  great 
tendency  to  commence  on  the  extremities,  especially  the  forearms. 
The  abdomen,  hips,  and  external  aspects  of  the  thighs  are  also 
often  implicated,  but  any  region  may  be  invaded. 

5.  It  is  generally  symmetrical. 

6.  Its  course  is  variable,  but  it  is  apt  to  continue,  on  and  off,  for 

^  In  the  description  -whicli  follows  I  owe  much  to  his  papers,  and  to  the  ad- 
mirable volume  of  Dr  Brocq,  entitled  De  la  Dermatite  herpdiforme  de  Duhring 
(Paris,  G.  Masson,  1888).  [See  review  of  this  work  at  page  928. — Ed. 
Edinburgh  Medical  Journal. 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    X.  T 


882  PROFESSOK   T.   M'CALL  ANDERSON   ON  [APRIL 

years,  relapses  being  the  rule,  and  the  lesions  often  differing  from 
those  of  the  primary  attack. 

7.  It  is  generally  met  with  in  adults,  and  in  males  much  more 
frequently  than  in  females.  In  the  latter  it  often  occurs  in  con- 
nexion with  pregnancy  (herpes  gestationis). 

8.  The  general  health  is  usually  not  much  interfered  with  by  it. 

9.  It  is  often  very  rebellious  to  treatment. 

The  principal  forms  of  the  disease  are  the  erythematous,  vesi- 
cular, bullous,  pustular,  and  papular. 

{a.)  Dermatitis  herpetiformis  erythematosa. — This  eruption  is  often 
preceded  and  accompanied  by  some  fever,  and  almost  always  by 
great  irritation  of  the  skin.  It  may  be  diffuse,  but  generally 
occurs  in  circumscribed  patches  of  erythematous  inflammation  ;  or 
it  may  present  a  semi-urticarial  character.  The  patches  have  a 
tendency  to  heal  in  the  centre,  which  remains  pigmented  for  a 
time,  and  to  spread  at  the  edges,  which  may  be  elevated ;  and 
when  neighbouring  patches  coalesce,  they  present  more  or  less  of 
a  marginate  outline.  At  first  they  have  a  bright  red  colour,  which 
is,  however,  soon  replaced  by  a  violet  tint.  There  is  generally  a 
tendency  to  the  development  of  papules,  vesico-papules,  or  diffuse 
infiltrations,  if  not  in  the  first  attack,  in  one  of  the  relapses.  The 
eruption,  which  leaves  behind  it  pigmented  stains  for  a  time,  may 
last  for  days  or  weeks,  or  it  may  pass  into  one  of  the  other 
varieties. 

(b.)  Dermatitis  herpetiformis  vesiculosa. — This  variety  starts  with 
the  gradual  development  of  irregularly-shaped  vesicles,  varying  in 
size  from  a  pin's  head  to  a  split  pea,  and  often  at  first  without 
inflammatory  areolae.  They  generally  occur  in  clusters,  and  when 
close  together  often  coalesce,  in  which  case  a  reddish  areola  is 
usually  present.  The  eruption  is,  as  a  rule,  abundant,  and  here 
and  there  papules,  vesico-papules,  vesico-pustules,  and  small  bullae 
may  make  their  appearance.  Intense  itching,  more  than  in  any 
other  variety  of  the  disease,  precedes  and  accompanies  the  out- 
break, and  burning  and  smarting  are  often  complained  of.  It  is 
the  most  common  variety  of  dermatitis  herpetiformis,  and  may 
attack  any  part;  but  the  neck,  back,  chest,  abdomen,  upper 
extremities,  and  thighs  are  most  frequently  implicated. 

(c.)  Dermatitis  herpetiformis  bullosa. — In  this  variety  the  bullae 
themselves  present  the  same  characters  as  are  found  in  pemphigus, 
and  vary  in  size  from  a  split  pea  to  a  walnut ;  but  they  have  a 
tendency  to  appear  in  clusters  of  two  or  three,  the  intervening  skin 
being  more  or  less  inflamed.  Moreover,  mingled  with  the  blebs, 
or  in  their  vicinity,  vesicles  and  pustules  are  usually  seen.  Other- 
wise this  eruption  presents  similar  characters  to  the  preceding 
varieties  as  regards  extent,  seat,  itching,  occurrence  in  successive 
crops,  etc.  This  is  probably  the  pemphigus  pruriginosus  of  eome 
authors. 

(d.)  Dermatitis  herpetiformis  pv^stulosa. — This  is  the  most  serious 


1889.]  DERMATITIS  HERPETIFORMIS.  883 

form,  and  is  usually  preceded  and  accompanied  by  considerable 
constitutional  disturbance  and  fever.  The  pustules,  which  develop 
slowly,  and  which  may  appear  at  any  part,  vary  in  size  from  that 
of  a  pin  head  to  that  of  a  split  pea,  and  are  surrounded  by  inflammatory 
areolae.  They  are  tense  or  flaccid,  and  have  a  tendency  to  dry  up 
in  the  centre  and  to  spread  circumferentially.  At  some  parts  they 
occur  in  groups,  and  sometimes  a  central  pustule  is  surrounded  by 
a  circle  of  smaller  ones,  as  in  herpes  iris.  Often  vesicles  and  bullae, 
papules,  and  vesico-papules,  are  mingled  with  the  pustules,  or 
appear  in  their  vicinity,  or  the  eruption  may  be  preceded  or 
followed  by  one  of  the  other  varieties  of  the  affection.  It  occurs 
in  successive  crops,  each  lasting  from  one  to  four  weeks,  and  with 
intervals  of  similar  or  of  longer  duration,  so  that  the  disease  may 
be  indefinitely  prolonged.  It  is  always  accompanied  by  intolerable 
irritation. 

(e.)  Dermatitis  herpetiformis  papulosa. — This,  the  rarest  and 
mildest  form,  is  characterized  by  the  development  of  groups  of 
two  or  three  reddish  or  violaceous  papules,  which  vary  in  size, 
like  the  vesicles  of  the  vesicular  form,  resembling  the  abortive 
vesicles  of  some  cases  of  zona,  although  at  times  they  vesicate  on 
their  summits.  They  are  generally  excoriated  by  the  patient's 
nails,  and  may  be  covered  with  scales  or  blood-crusts.  The  erup- 
tion pursues  a  chronic  course,  lasting  often  a  number  of  weeks ; 
and,  as  in  the  other  varieties,  is  followed  by  more  or  less  pigmenta- 
tion of  the  skin.     Eelapses  are  to  be  expected. 

In  not  a  few  cases  of  Dermatitis  herpetiformis  all  forms  of  the 
disease  are  represented  during  the  course  of  the  illness ;  or  at  one 
and  the  same  time  there  may  be  a  mixture  of  lesions  with  no 
single  type  predominating,  just  as  in  eczema  several  lesions  may 
be  recognised  at  different  parts,  or  even  on  the  same  patch.  When 
new  crops  of  eruption  are  appearing  diarrhoea  is  far  from  un- 
common, which  leads  to  the  suspicion  that  perhaps  a  similar 
eruption  is  developing  on  the  intestinal  mucous  membrane. 

This  is  probably  not  such  a  rare  disease  as  statistics  might  lead 
us  to  suppose,  for,  no  doubt,  many  of  the  cases  met  with  have  been 
classed  under  other  heads,  such  as  pemphigus  and  erythema  multi- 
forme. From  the  statistics  collected  by  Dr  Brocq,  the  following 
facts  may  be  gathered  with  regard  to  it.  It  occurs  much  more 
frequently  in  males  than  in  females,  in  the  proportion  of  at  least 
two  to  one,  and  this  is  especially  true  of  the  more  serious  cases. 
It  is  met  with  at  all  ages,  but  is  most  common  in  adults,  particu- 
larly between  16  and  30,  and  from  47  to  62  years;  and  the  more 
severe  cases  appear,  as  a  rule,  in  those  who  have  passed  middle 
life.  It  sets  in  at  all  seasons,  but  perhaps  oftenest  in  spring  and 
autumn.  Its  connexion  with  the  rheumatic  diathesis  is  not  clear ; 
at  all  events,  it  is  manifestly  erroneous  to  consider  it  in  the  light 
of  a  rheumatic  affection  as  Bazin  did  (hence  the  name  pemphigus 
arthritique.)     But  there  can  be  little  doubt  that  persons  of  the 


884  PROFESSOR  T.   M'CALL   ANDERSON   ON  [APRIL 

nervous  temperament,  and  those  whose  nervous  systems  have 
been  overstrained  or  worn  out,  are  liable  to  attack.  That  it  is  a 
dermato-neurosis  is  further  supported  by  the  circumstance  that  it 
is  a  symmetrical  eruption  ;  that  it  not  unfrequently  partakes  of  an 
urticarial  character ;  that  intense  irritation  accompanies  and  often 
precedes  the  outbreak ;  and  that  nerve  tonics  afford  the  best  pros- 
pect of  a  cure. 

In  many  cases  the  general  health  is  remarkably  well  maintained 
and  the  appetite  continues  good,  even  when  the  eruption  is  exten- 
sive, the  irritation  extreme,  and  the  sleep  disturbed.  The  whole 
duration  of  the  disease  is  indefinite  :  it  often  lasts,  on  and  off,  for 
years,  and  it  is  occasionally  fatal,  although  generally  as  the  result 
of  some  complication. 

The  disease  described  by  Milton  in  1872  under  the  head  of 
Herpes  gestationis  (Hydroa  gestationis  of  Liveing,  Erythema  gesta- 
tionis  of  Wyndham  Cottle,  Dermatite  polymorphe  prurigineuse 
r^cidivante  de  la  grossesse  of  Brocq),  must  be  regarded  in  the  light 
of  a  variety  of  Dermatitis  herpetiformis,  seeing  that  the  characters 
of  the  two  affections  are,  in  most  respects,  identical.  The  former, 
however,  presents  the  following  peculiarities : — 

1.  The  eruption,  like  that  of  Dermatitis  herpetiformis,  generally 
commences  on  the  extremities,  but  the  hands  and  arms  are  gener- 
ally first  attacked,  or  occasionally  the  umbilicus. 

2.  It  never  assumes  the  pustular  form,  and,  when  bullous,  the 
contents  of  the  bullae  rarely  become  purulent. 

3.  It  always  sets  in  during  (and  usually  during  the  last  six 
months  of)  pregnancy,  or  a  few  days  after  confinement ;  and,  in 
the  former  case,  there  is  generally  a  relapse  or  recrudescence  a 
few  days  after  delivery. 

4.  It  has  a  great  tendency  to  return,  and  in  an  aggravated  form, 
in  subsequent,  though  not  necessarily  in  all,  pregnancies.  But 
after  several  attacks  during  pregnancy,  it  may  persist  for  a  long 
time  independent  of  that  condition. 

The  disease  described  by  Hebra  in  1872  under  the  name  of 
Impetigo  herpetiformis'^  (Herpes  pysemicus  of  Auspitz,  Metastatic 
pustulosis  of  Neumann),  though  presenting  some  of  the  features  of, 
and  considered  by  Duhring  to  be  identical  with,  the  pustular  form 
of  Dermatitis  herpetiformis,  must  be  differentiated  from  it.  The 
following  are  its  most  salient  features  : — 

1.  In  all  the  recorded  cases  it  occurred  in  pregnant  or  puerperal 
females,  with  one  exception,  reported  by  Kaposi — that  of  a  young 
man,  set.  20,  who  succumbed  in  a  few  weeks  to  a  purulent  tuber- 
cular peritonitis. 

2.  It  almost  always  commences  on  the  inner  aspect  of  the  thighs, 
whence  it  spreads  to  the  abdomen,  mammae,  extremities,  hands 

1  Wiener  Med.  Wochenschrift,  1872,  No.  48.  A  very  full  account  of  this 
aflfection  was  recently  published  by  Kaposi  in  the  Vierteljahr  fiir  Derm,  und 
Syph.,  vol.  xiv.,  1887,  p.  273. 


1889.]  DERMATITIS  HERPETIFORMIS.  885 

and  feet,  and,  lastly,  to  the  neck  and  head.  The  mucous  mem- 
branes are  also  often  invaded,  especially  the  mucous  membrane  of 
the  mouth. 

3.  The  eruption  consists  of  groups  of  superficial  pustules,  the 
size  of  pin  heads,  with  inflammatory  areolae.  These  dry  up  into 
dirty  brown  crusts,  around  which  new  pustules  form.  These,  in 
their  turn,  form  crusts,  and  so  the  process  extends  until  the  erup- 
tion becomes  confluent,  and  involves  a  great  extent  of  surface. 
When  the  crusts  fall  there  is  no  ulceration  to  be  seen,  but  a  deli- 
cate red  new  skin,  or  a  surface  which  is  infiltrated,  and  often 
exuding  like  a  weeping  eczema.  Sometimes  a  similar  eruption 
appears  on  the  tongue  and  pharynx. 

4.  There  is  marked  elevation  of  temperature,  and  shiverings 
are  usual  with  each  new  crop  of  pustules. 

5.  It  is  almost  invariably  fatal.  Of  twelve  cases  observed  in 
Vienna,  nine  were  fatal  in  the  first  attack,  and  two,  owing  to 
relapses,  in  subsequent  pregnancies,  while  only  one  patient  per- 
manently recovered. 

It  will  thus  be  seen  that  it  differs  materially  from  Duhring's 
Dermatitis  herpetiformis  pustulosa,  especially  in  that  it  attacks 
pregnant  and  puerperal  females  almost  exclusively,  is  pustular  in 
character  throughout,  is  attended  by  high  fever,  but  unaccom- 
panied by  itching,  and  is  almost  invariably  fatal. 

The  diagnosis  of  Dermatitis  herpetiformis  is  sometimes  difficult, 
and  it  may  be  mistaken  for  Erythema  multiforme.  Eczema,  Lichen, 
Urticaria  bullosa,  and  Pemphigus. 

Erythema  multiforme  resembles  it  in  its  polymorphous  nature 
and  relapsing  character,  but  presents  a  good  many  distinctive 
features. 

1.  It  has  a  much  more  marked  tendency  to  appear  in  spring 
and  autumn. 

2.  It  generally  attacks  young  adults,  while  dermatitis  herpeti- 
formis may  occur  at  any  age  (although  specially  between  16  and 
30  and  from  47  to  62). 

3.  Its  duration  is  much  shorter,  generally  from  one  to  four 
weeks,  although  it  may  be  prolonged  by  successive  crops  of 
eruption. 

4.  Its  special  seats  of  predilection  are  the  backs  of  the  hands, 
fingers,  and  forearms,  the  dorsum  of  the  feet,  and  the  fronts  of  the 
legs. 

5.  The  eruption  has  far  less  tendency  to  become  vesicular,  pus- 
tular, or  bullous. 

6.  Itching  and  burning  are  not  prominent  symptoms. 

Eczema  may  be  mistaken  for  it,  but  in  the  latter  the  vesicles 
are  much  more  variable  in  size,  their  form  is  more  irregular,  they 
do  not  rupture  so  readily,  and  they  have  a  greater  tendency  to 
grouping.  The  constitutional  disturbance  is  more  marked,  the 
itching  more  intense  and  continuous,  and  the  soothing  applications. 


886  DEEMATITIS   HERPETIFORMIS.  [APRIL 

SO  generally  useful  in  vesicular  eczema,  are  not  nearly  so  efficacious. 
The  disease,  too,  is  much  more  chronic  and  more  liable  to  relapse. 

Lichenotis  eczema  may  be  mistaken  for  Dermatitis  herpetiformis 
papulosa,  but,  in  the  latter,  the  tendency  to  grouping  and  the 
slow  evolution  of  the  papules,  as  well  as  the  liability  to  the  occur- 
rence of  successive  crops  at  irregular  intervals,  and  the  obstinacy 
with  which  it  resists  treatment,  should  prevent  error. 

Urticaria  bullosa  may  be  confounded  with  Dermatitis  herpeti- 
formis when  the  urticarial  element  is  well  marked  in  the  latter. 
But  in  the  former  the  urticaria  eruption  is  readily  excited  by 
irritating  the  skin ;  the  bullae,  as  a  rule,  are  much  scantier,  and 
they  always  form  upon  an  urticarial  patch. 

Pemphigus  may  be  distinguished  from  dermatitis  herpetiformis 
bullosa  by  attention  to  the  following  points : — 

1.  In  pemphigus  the  general  health  is  usually  much  more 
deteriorated,  especially  in  the  later  stages. 

2.  The  bullae  have  not  the  same  tendency  to  grouping,  and,  as  a 
rule,  are  larger. 

3.  The  polymorphous  character  of  the  eruption  is  either  want- 
ing, or  is  not  a  prominent  feature,  nor  is  there  the  same  variability 
in  the  character  of  the  lesions  at  different  periods. 

4.  Itching  and  burning  are  either  absent  or  slight  as  a  rule. 

5.  The  disease  occurs  with  equal  frequency  in  males  and  females, 
whereas  males  are  much  more  frequently  attacked  in  Dermatitis 
herpetiformis  (in  the  proportion  of  two  to  one). 

Treatment. — Bearing  in  mind  the  view,  generally  entertained, 
that  this  is  a  tropho-neurosis,  it  is  obvious  that  tonics,  especially 
nerve  tonics,  are  indicated,  such  as  strychnia,  phosphorus,  quinine 
in  large  doses,  and,  above  all,  arsenic.  The  arsenic  must  be  given 
in  full  and  increasing  doses,  and  when  it  fails  by  the  mouth,  it 
should  be  administered  subcutaneously.  Before  using  tonics,  any 
derangement  of  the  general  health  must  be  corrected  on  general 
principles.  Overwork,  over-excitement,  and  worry  should  be  care- 
fully avoided. 

Local  treatment  is  merely  palliative,  and  much  relief  is  often 
afforded  by  puncturing  the  vesicles  and  bullae.  Sedative  lotions 
and  ointments,  such  as  are  used  in  the  treatment  of  acute  attacks 
of  eczema,  and  which  need  not  be  particularized  here,  are  likewise 
indicated. 

In  cases  of  Impetigo  herpetiformis  we  should,  in  addition,  endea- 
vour to  maintain  the  patient's  strength,  and  to  keep  the  fever  in 
check  by  means  of  antipyretics,  but  we  must  not  be  too  sanguine 
of  success. 


1889.]  PHENOMENA  IN   CHEYNE-STOKES   RESPIRATION.  887 

II.— AN  EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 
STOKES  RESPIRATION. 
By  Q.  A.  Gibson,  M.D.,  D.Sc. 
{Continued  from  page  813.) 

Zimmerman^  describes  the  case  of  a  drunken  tailor,  aged  55,  who 
was  seen  in  an  epileptic  attack  caused  by  excess.  He  had  been 
healthy  up  to  within  a  few  years  of  this  attack,  but  latterly  he  had 
suffered  from  breathlessness,  and  he  had  also  been  affected  by 
phlegmonous  inflammation  of  the  leg.  After  the  epileptic  seizure  he 
became  oedematous,  with  a  return  of  the  inflammation  of  the  leg  and 
severe  dyspnoea.  The  urine  contained  neither  albumen  nor  tube- 
casts.  About  a  month  after  being  first  seen  the  breathing  assumed 
the  Cheyne-Stokes  character,  and  traces  of  albumen  appeared  in 
the  urine,  but  without  casts.  The  patient  died  in  a  comatose  state, 
and  it  was  found  on  post-mortem  examination  that  there  was 
chronic  renal  disease  with  cardiac  hypertrophy,  arterial  atheroma, 
and  cerebral  congestion.  The  author  quotes  Cuffer's  cases  and 
explanation,  and  refers  to  the  work  of  Biot.  He  further  states 
that  since  the  paper  was  read  he  had  met  with  Cheyne-Stokes 
respiration  in  an  old  man  of  80,  dying  of  chronic  bronchitis 
and  emphysema,  and  in  a  child  18  months  old  suffering  from  pneu- 
monia of  the  right  lung.  In  this  last  case  the  patient  had  many 
symptoms  pointing  to  tubercular  meningitis,  but  recovered,  and 
the  Cheyne-Stokes  breathing  in  this  instance  was  not  continuously 
present,  but  appeared  and  disappeared  irregularly. 

Luciani"  prefaces  one  of  the  most  valuable  contributions  ever 
made  to  this  subject  by  stating  that  he  had,  in  the  year  1873,  com- 
menced a  series  of  experiments  under  the  superintendence  of 
Ludwig  at  Leipzig,  but  that  on  account  of  various  circumstances 
he  had  not  been  able  at  the  time  to  complete  his  investigations. 
This  paper  begins  with  a  brief  retrospect  of  the  work  done  by  pre- 
vious observers,  after  which  the  author  describes  some  of  the 
results  which  he  obtained  by  experiment.  Finding,  by  means  of 
operations  on  the  heart  of  the  frog,  that  its  rhythmic  contractions 
became  periodic,  the  analogy  between  this  phenomenon  and 
the  character  of  the  rhythm  of  Cheyne-Stokes  respiration  led  him 
to  seek  for  their  causes  in  a  common  condition.  His  experiments 
were  conducted  by  fixing  a  rabbit  in  Czermak's  apparatus ;  liga- 
turing the  carotid  arteries  to  control  haemorrhage  during  subsequent 
operations  on  the  medulla ;  connecting  the  respiratory  passage,  by 
means  of  a  canula,  with  a  manometer,  whose  index  recorded  the 
respiratory  movements  on  a  revolving  cylinder ;  exposing  the 
medulla  oblongata ;  and  dividing  it  above  the  origin  of  the 
vagi.     The  respiratory  movements  after  section  of  the  medulla 

^  Canadian  Journal  of  Medical  Science,  vol.  iv.  p.  112,  1879. 

*  Lo  Sperinientale.    Anno  xxxiii.    Tomo  xliii.  p.  341  e  p.  449,  1879. 


S88  DR   G.   A.   GIBSON   ON   THE  [aPUIL 

in  this  way  fell  into  groups,  but  each  group  began  with  a  deep 
inspiration  and  expiration,  followed  by  a  series  of  diminishing 
respirations.  Luciani  states  that  if  he  had  published  these  ob- 
servations when  they  were  conducted  he  would  have  deprived 
Filehne  of  some  of  the  novelty  of  his  work,  but  he  would  at  the 
same  time  have  been  led  to  different  conclusions.  He  was  induced, 
however,  by  the  hope  of  obtaining  more  precise  information,  to  post- 
pone the  publication  of  these  results. 

He  afterwards  turned  himself  to  the  study  of  apncea  caused  by 
excess  of  artificial  respiration.  The  method  employed  was  to  fix  the 
dog  or  rabbit ;  to  inject  laudanum  into  the  veins  of  the  dog,  when 
such  an  animal  was  subjected  to  experiment,  this  proceeding  not 
being  resorted  to  in  the  case  of  the  rabbit ;  to  perform  tracheotomy 
and  insert  a  canula  into  the  trachea  for  the  purpose  of  supporting 
artificial  respiration  and  recording  respiration;  to  expose  the  vagi;  to 
keep  up  artificial  respiration  until  apnoea  was  present ;  to  divide  the 
vagi ;  and  in  some  cases  to  join  the  canula  to  a  reservoir  of  air  lead- 
ing by  a  tube  to  a  Marey's  tambour,  by  which  means  the  result  of 
gradual  asphyxia  could  be  recorded.  He  found  that,  after  the  pro- 
duction of  apnoea  by  excessive  artificial  respiration,  and  without 
section  of  the  vagi,  the  respiration  did  not  at  once  begin  as  ordinary 
respiration,  but  in  an  ascending  series ;  at  the  same  stage,  with 
previous  section  of  the  vagi,  an  ascending  series  of  respirations  was 
seen,  but  in  this  case  the  ascent  was  much  more  rapid ;  after  pro- 
found narcosis  had  been  caused  and  apnoea  induced,  it  was  suc- 
ceeded by  groups  of  ascending  and  descending  respirations,  separated 
by  long  pauses ;  after  section  of  one  vagus,  the  breathing  became 
deeper  but  less  frequent,  and  after  section  of  the  other  also  it 
became  laboured  and  very  infrequent  ;  when  the  animal  was 
allowed  to  breathe  the  air  of  the  reservoir  until  death  from  asphyxia 
took  place,  it  was  found  that  section  of  the  vagi  caused  but  little 
effect,  and  the  respiration  became  periodic  when  the  animal  was 
almost  asphyxiated. 

Turning  to  the  clinical  aspect  of  the  subject,  Luciani  remarks 
that  Cheyne-Stokes  respiration  may  occur  in  diseases  of  the 
brain,  and  of  the  heart  and  great  vessels,  in  the  coma  produced 
by  different  intoxications,  during  the  agony  of  certain  affec- 
tions, and  also  in  the  sleep  of  healthy  persons  and  the  lethargy  of 
hibernating  animals.  He  refers  to  its  appearance  after  the  use  of 
morphine  in  disease ;  after  the  administration  of  morphine  followed 
by  ether  or  chloroform ;  after  the  injection  of  chloral,  kreatin,  and 
ammonium  carbonate ;  after  injury  to  the  parts  near  the  noeud 
vital ;  after  the  employment  of  artificial  respiration,  subsequent  to 
the  injection  of  opium  into  the  veins,  so  as  to  cause  apncea ;  and 
during  the  last  stage  of  asphyxia. 

The  respiratory  phenomenon  may  appear  in  different  forms. 
The  movements  may  increase  or  decrease  in  amplitude  without 
change  in  frequency,  or  there  may  be  more  of  the  descending  than 


1889.]  PHENOMENA  IN  CHEYNE-STOKES  RESPIKATION,  889 

ascending  phase — in  fact,  the  latter  may  be  absent.  The  number 
of  respirations  during  a  period  may  vary  from  two  to  thirty,  but 
the  larger  numbers  are  only  found  in  the  Cheyne-Stokes  breathing 
of  disease.  The  length  of  the  pauses  is  very  variable,  and  there 
may  be  a  similarity  in  the  duration  of  the  successive  pauses  or  a 
total  want  of  equality. 

The  author  then  enters  upon  a  long  and  careful  criticism  of  the 
theories  of  Traube,  Filehne,  and  Hein, — into  which  it  is,  for 
obvious  reasons,  impossible  to  follow  him, — after  which  he  submits 
his  own  views  on  the  subject. 

He  is  of  opinion  that  it  is  impossible  to  solve  the  problem  of 
Cheyne-Stokes  respiration  while  resting  upon  the  principle  now 
generally  admitted  or  sustained,  that  the  capacity  and  functional 
activity  of  a  nervous  organ  has  always  a  direct  and  immediate 
dependence  on  the  stimulant  and  nutritive  conditions  extrinsic  to 
itself.  That  the  life  of  an  organ  is  intimately  bound  up  with  the 
surrounding  conditions  and  influences  cannot  be  denied  without 
stifling  science  in  the  old  vitalism ;  but  it  does  not  follow  from 
this  that  the  organ  does  nothing  in  every  case  but  to  transform  as 
much  as  it  receives  in  a  given  time,  both  in  the  same  measure  and 
in  the  same  rhythm  with  which  it  receives  it.  Drawing  a  clear 
line  of  distinction  between  reflex  and  automatic  movements, 
Luciani  points  out  that  the  determining  cause  of  the  former  is 
extrinsic,  while  in  the  case  of  the  latter  it  is  intrinsic,  and  consists 
in  oscillations  of  the  internal  nutritive  movements,  to  which  cor- 
respond as  many  oscillations  of  the  excitability  of  the  organ  itself. 
He  was  led  to  this  new  conception  of  automatism  by  the  dis- 
covery of  the  periodic  grouping  of  the  movements  of  the  frog's 
heart,  before  referred  to,  for  no  one  could  doubt  that  when  extrinsic 
conditions  remained  unchanged  the  cause  of  the  alternate  groups 
of  pulsations  and  pauses  in  repose  was  intrinsic. 

Luciani  therefore  regards  the  diverse  forms  of  respiratory 
rhythm  as  extrinsic  expressions  corresponding  to  the  oscilla- 
tions of  the  nutritive  changes  taking  place  in  the  structure  of  the 
respiratory  centre.  If  it  be  granted  that  the  respiratory  centre  is 
automatic,  it  follows  that  the  different  forms  of  rhythm  which  con- 
stitute Cheyne-Stokes  phenomenon  may  be  regarded  as  effects  of 
diverse  kinds  of  automatic  oscillations  in  the  excitability  of  the 
centre  itself. 

In  a  study  of  the  action  of  morphine  on  the  respiration,  Filehne  * 
again  discusses  the  respiratory  and  circulatory  phenomena  of  Cheyne- 
Stokes  breathing,  and  somewhat  modifies  his  original  statements. 
He  says : — "  To  my  former  theory  of  periodic  breathing  would  I 
now  make  the  addition  that  for  its  appearance  it  is  quite  sufficient 
that  the  arteries  of  the  medulla  oblongata  be  stimulated  simul- 
taneously with  the  stimulation  of  the  respiratory  centre ;  a  previous 

^  Archiv  fiir  experimentelU  Pathologie  und  Pharviakologie,  x.  Band,  S.  442, 
und  xi.  Band,  S.  45,  1879. 

EDINliUKGH    MED.    JOURN.,   VOL.    XXXIV. — NO.   X.  5  U 


890  DR  G.   A.   GIBSON  ON  THE  [ APRIL 

contraction  will  strengthen  the  phenomenon,  and  may  occur  in  the 
most  pronounced  cases ;  it  is,  however,  not  indispensable,  and  per- 
haps not  always  present."  He  further  says  that  the  difference  of 
opinion  existing  between  his  own  and  Biot's  explanations  of  iden- 
tical observations  is  a  purely  verbal  misunderstanding  ;  and  he  also 
replies  to  Hein  by  saying  that  the  latter  has  concerned  himself 
more  with  the  how  than  the  why. 

To  Rosenbach^  we  owe  a  new  explanation  of  the  symptom  in 
question.  After  pointing  out  that  the  different  phenomena  accom- 
panying Cheyne-Stokes  respiration  really  constitute  a  complex  of 
symptoms,  he  disputes  Biot's  statement  that  true  Cheyne-Stokes 
respiration  only  occurs  in  cardiac  diseases,  and  not  in  cerebral 
affections.  He  points  out  that  the  descending  part  of  the  phase 
of  respiration  is  not  so  regular  as  the  ascending,  and  agrees  with 
most  observers  that  the  circulation  is  sometimes  involved  and  at 
other  times  not.  In  some  cases  he  mentions  that  there  is  a  rise 
of  the  pressure  and  fall  of  the  rate  during  the  ascending  respira- 
tion, while  with  the  descending  respiration  the  contrary  takes 
place,  and  in  other  cases  there  is  no  increase  of  rate,  only  lessened 
frequency  at  the  end  of  the  pause.  He  shows  that  Filehne's  ob- 
servation on  the  sinking  of  the  fontanelles  of  the  child's  head 
before  the  beginning  of  the  respiratory  phase  is  not  correct  for  all 
cases ;  the  recession  may  occur  after  the  phase  has  begun  or  during 
the  height  of  the  breathing,  from  which  he  concludes  that  the 
sinking  may  be  caused  by  an  acceleration  of  the  blood-flow  from 
the  brain  by  means  of  the  respiration.  He  recalls  Leube's  state- 
ment regarding  stimulation  of  the  phrenic  nerves,  and  says  that 
stimulation  of  the  vagi,  causing  a  change  in  the  pulse  rate,  effects 
no  change  in  the  phenomena  of  Cheyne-Stokes  respiration,  showing 
that  they  are  independent  of  the  supply  of  arterializcd  blood  to 
the  brain.  He  lays  stress  on  the  contraction  of  the  pupils  during 
the  pause  and  their  dilatation  during  the  period  of  breathing,  as 
well  as  on  the  rolling  of  the  eyeballs  or  conjugate  deviation,  and 
the  general  twitchings  of  the  body  occurring  during  the  period  of 
respiration.  He  further  dwells  on  the  changes  in  the  sensorium, 
and  on  the  influence  of  such  drugs  as  morphine,  chloral,  and 
bromide  of  potassium,  and  recapitulates  that  there  are  changes  in 
Cheyne-Stokes  respiration  connected  with  the  cortical  as  well  as 
with  the  basal  centres,  such  as  those  of  intellection,  the  muscular 
system,  the  vision,  the  circulation,  and  the  respiration. 

Passing  by  Traube's  first  explanation,  he  states  his  second,  which, 
though  not  entirely  tenable,  has  yet  some  good  points.  He  points 
out  that  it  does  not  explain  the  ascending  character  of  the  respira- 
tion. He  then  enunciates  Filehne's  earlier  theory,  based  on 
periodic  changes  of  blood-supply,  caused  by  a  higher  degree  of 
excitabihty  of  the  vaso-motor  centre,  and  without  hesitation  rejects 
it,  inasmuch  as  in  some  cases  the  blood-pressure  rises  before  the 
^  Zeitschrift  fiir  klinische  Medicin,  i.  Band,  S.  583,  1879. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  891 

recommencement  of  breathing,  and  when  this  rise  is  present  it 
attains  its  maximum  at  a  point  between  the  ascending  and  de- 
scending respirations.  Filehne's  later  theory,  that  the  stimulation 
of  the  respiratory  centre  and  medullary  vessels  may  occur  simul- 
taneously is  also  rejected.  Eosenbach  is  of  opinion  that  both 
phenomena  are  co-effects,  and  he  is  strengthened  in  his  views  by 
the  fact  that  other  phenomena,  such  as  the  mental,  visual,  and 
muscular,  are  bound  up  with  the  respiratory,  not  with  the  circu- 
latory, symptoms.  He  emphasizes  the  differences  between  the 
circulatory  and  respiratory  phenomena  in  this  type  of  breathing, 
the  great  variability  of  the  former  and  the  monotonous  similarity 
of  the  latter  being  noteworthy.  He  brings  forward  the  fact,  noted 
by  Leube  and  confirmed  by  himself,  that  artificial  respiration  during 
the  pause  (which  prevents  accumulation  of  carbonic  acid  in  the 
blood)  does  not  alter  the  next  phase,  as  well  as  his  own  observation 
that  stimulation  of  the  vagi  and  slowing  of  the  pulse  during  the 
descending  period  do  not  alter  that  phase,  and  holds  that  these 
facts  prove  that  within  wide  limits  the  condition  of  the  blood  does 
not  modify  the  type  of  respiration.  He  points  out  that  the  eye 
phenomena  are  not  dependent  on  the  state  of  the  blood,  as  the 
widening  of  the  pupils  takes  place  along  with  the  first  inspiration, 
and  therefore  before  any  change  can  be  effected  in  the  state  of  the 
blood.  In  this  connexion  he  refers  to  the  work  of  Kussmaul, 
Rahlmann  and  Witkowski,  Sander,  Plotke,  and  himself,  on  the 
relations  of  the  eye  and  the  central  nervous  system.  He  is  there- 
fore led  to  conclude  that  the  beginning  and  ending  of  breathing  in 
Cheyne-Stokes  respiration  are  independent  of  the  blood-pressure 
and  the  amount  of  gas  in  the  blood,  and  that  the  changes  of  the 
pupils  have  no  relation  to  the  circulation  or  the  blood,  but  to  the 
excitability  of  centres  not  directly  dependent  on  the  condition  of 
the  blood.  He  points  out  that  in  health  the  vagus  and  vaso-motor 
centres  are  more  excitable  than  the  respiratory,  but  that  in  this 
phenomenon  (with  the  highest  pressure  accompanying  the  deepest 
respirations)  they  are  sunk  to  the  level  of  the  respiratory.  He  asserts 
that  Filehne's  theory  postulates,  in  rhytlimic  contraction  and  dilata- 
tion of  the  arterial  system,  conditions  without  analogy  in  nature. 
He  points  out  that  at  the  end  of  the  period  of  breathing  there  is  no 
apnoea,  for  the  pupils,  eyeballs,  and  mental  state  speak  of  fatigue, 
not  better  arterialization,  that  amyl  nitrite  has  often  no  influ- 
ence or  very  little,  and  that  the  drug  is  believed  by  some  to  act  on 
the  respiratory  centre  itself.  He  refers  to  Hein's  explanation 
of  the  observation  that  unconsciousness  is  present  during  the  pause 
and  consciousness  during  the  period  as  incompatible  with  Filehne's 
theory. 

Eosenbach  seeks  for  an  explanation  of  the  phenomenon  in  the 
alternation  of  activity  and  repose  characteristic  of  nature.  In  the 
respiration  there  is  inspiration,  expiration,  and  pause ;  in  the  cir- 
culation, systole,  diastole,  and  pause ;  in  the  nervous  system,  waking 


892  DR  G.   A.   GIBSON   ON  THE  [APRIL 

and  sleep ;  while  in  cnrarized  animals  there  are  periodic  changes  in 
the  rate  and  tension  of  the  circulation  which  are  quite  independent 
of  the  respiration.  The  origin  of  activity  is  in  the  cell,  not  the 
Uoocl,  and  it  is  illogical  to  seek  a  cause  of  respiratory  and  other 
phenomena  in  the  blood.  Periodicity  of  activity  of  all  nervous 
apparatus,  therefore,  depends  on  immanent  peculiarities  of  element- 
ary structures,  and  the  blood  is  not  the  direct  stimulus  for  the  cells, 
but  has  its  power  in  giving  the  cells  the  possibility  of  regulating 
tissue  change.  When  the  blood  is  altered  there  is  necessarily  a 
modification  in  the  absorption  of  oxygen  and  removal  of  tissue 
change  products,  and  the  mechanism  will  therefore  be  indirectly 
affected ;  the  blood  is  thus  only  one  link  in  the  chain  of  apparatus 
needful  for  life. 

The  regular  alternation  of  activity  and  repose  characteristic  of 
life  is  seen  in  the  complex  of  pathological  phenomena,  of 
which  periodic  breathing  is  only  one  symptom,  and  Cheyne- 
Stokes  respiration  is  therefore  a  condition  in  which  the  ex- 
haustibility  of  the  central  apparatus,  normally  following  its 
activity,  is  greatly  increased.  The  respiratory  centre  has  its 
irritability  lowered,  as  the  breathing  is  at  first  shallow,  but  the 
irritability  progressively  increases,  for  in  spite  of  better  aeration 
dyspnoea  gradually  develops.  The  irritability  then  diminishes 
and  the  descending  phase  begins.  The  supposition  may  be  hazarded 
that  the  first  descending  respirations  following  the  deepest  have  their 
origin  in  better  arterialization  of  the  blood,  or  in  removal  of  waste 
products  from  the  centre,  and  that  the  fall  in  irritability  begins 
with  the  first  normal  breathing. 

Eosenbach  shortly  summarizes  his  views  in  this  way: — Through 
certain  disturbances  of  nutrition,  the  brain  suffers  from  lessened 
flow  of  blood  or  altered  quality  of  blood,  and  the  processes  of  tissue 
change  are  modified  in  the  entire  central  organs,  or  in  particular 
parts  of  it,  especially  in  the  medulla  oblongata,  and  here  again 
more  particularly  in  the  respiratory  centre,  so  that  the  normal 
irritability  of  the  parts  is  lowered  more  or  less,  and  the  normal 
periodic  exhaustibility  is  increased  even  to  complete  paralysis. 

Rosenbach  mentions,  as  an  appendix  to  his  paper,  a  case  in 
which  a  patient  ill  with  tubercular  meningitis  suddenly  ceased  to 
breathe  except  once  or  twice  per  minute,  the  pulse  continuing  to 
beat.  After  artificial  respiration  had  been  employed  the  pheno- 
mena of  Cheyne-Stokes  breathing  appeared. 

Purjesz^  describes  a  case  which  he  met  with  in  the  University 
clinique  of  Wagner  in  Buda-Pesth.  The  patient,  a  man  aged  57, 
was  suffering  from  emphysema,  renal  cirrhosis,  cardiac  hyper- 
trophy, and  general  dropsy.  During  the  last  three  days  of  his 
life  typical  Cheyne-Stokes  breathing  was  present.  No  changes  in 
the  state  of  the  pupils  or  alterations  in  the  conditions  of  the 
brain  cortex  were  to  be  seen.    The  author  mentions  another  patient, 

1  Pester  viedicinisch-chirurgische  Presse,  xv.  Eancl,  SS.  771,  787,  u.  846,  1879. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   EESPIRATION.  893 

in  the  same  clinique,  suffering  from  chronic  renal  cirrhosis,  who 
had  Cheyne-Stokes  breathing.  In  this  case  an  improvement  in 
the  patient's  condition  took  place,  and  he  left  the  hospital. 
Purjesz  reviews  at  considerable  leiigth  several  of  the  theories 
which  have  been  advanced  to  account  for  the  phenomenon,  but 
gives  no  opinion  of  his  own. 

Edes^  has  described  five  cases  in  which  Cheyne-Stokes  breathing 
made  its  appearance  ;  and  it  is  a  most  interesting  point  to  find 
that  four  of  these  instances  belonged  to  the  same  family — a  father, 
aged  80  ;  his  wife,  whose  age  is  not  stated ;  and  two  sons,  aged 
respectively  50  and  45.  The  father  was  subject  to  attacks  of  un- 
consciousness, during  which  the  pulse  was  completely  lost  and  the 
periodic  respiration  appeared.  The  mother  and  the  two  sons  were 
affected  by  chronic  renal  disease.  The  fifth  case  was  that  of  an 
old  woman  with  chronic  renal  disease,  atheromatous  arteries,  and 
hypertrophy  of  the  heart,  in  whom  left  hemiplegia  occurred  from 
plugghig  of  the  middle  cerebral  artery. 

Kronecker  and  Marckwald,^  by  a  series  of  experiments  on  the 
rabbit,  have  shown  some  results  of  interest  in  this  connexion. 
The  medulla  was  severed  between  the  respiratory  centre  and  the 
brain,  in  such  a  way  that  the  respiration  was  not  much  altered, 
and  the  lower  part  was  stimulated  by  single  opening  induction 
shocks.  At  the  right  time  such  shocks  strengthened  the  inspira- 
tion and  expiration,  and  when  given  during  the  interval  between 
the  acts  they  induced  others  quite  normal  in  character.  When 
the  animal  was  brought  into  the  condition  of  apnoea  by  means  of 
artificial  respiration,  the  most  powerful  induction  shocks  failed  to 
cause  any  inspirations.  Wlien  long  pauses  in  the  respiration  with 
intervening  periods  of  dyspnoea  were  produced  by  partial  removal 
of  the  respiratory  centre,  every  induction  shock  given  during  the 
pauses  was  followed  by  an  apparently  normal  respiration.  When 
during  a  respiratory  pause  successive  rhythmic  induction  shocks 
were  given,  phenomena  were  seen  analogous  to  the  changes  in  the 
ventricle  of  the  frog's  heart  observed  by  Kronecker  and  Bowditch 
(Bowditch's  stair). 

From  the  pen  of  Eosenbach^  came  an  excellent  article  on  the 
subject,  based  upon  the  views  to  which  full  reference  has  been 
made.  In  this  article  he  again  advances  his  opinions  that  the 
phenomena  are  not  chiefly  dependent  on  changes  in  the  circula- 
tion, that  they  are  independent  of  any  periodicity  in  the  blood 
supply  to  the  brain,  and  that  they  are  co-ordinated  by  and 
joint  effects  of  one  and  the  same  cause  occurring  periodically  in 
the  central  organs,  this  cause  being  a  periodic  exhaustion  of  the 
centres.     The  whole  brain  may  be  affected,  when  the  entire  com- 

1  Boston  Medical  and  Surgical  Journal,  vol.  ci.  p.  734,  1879. 

2  Archiv  fiir  Physiologie,  Jahrgang  1879,  S.  592. 

3  Real-Encyclopcidie  der  gesammten  Heilkunde,  Herausgegeben  von  Dr  Albert 
Eiilenberg,  iii.  Band,  S.  150,  1880. 


894  DR   G.    A.    GIBSON   ON   THE  [APRIL 

plex  of  symptoms,  to  be  termed  Cheyne-Stokes  phenomenon,  is 
produced ;  or  only  limited  tracts  may  be  implicated,  giving  simply 
Cheyne-Stokes  breathing.  He  points  out  that,  just  as  the  respira- 
tory centre  alone  may  be  deranged,  so  the  vaso-motor  or  vagus 
centre  may  be  disturbed,  as  in  tubercular  meningitis,  and  cause 
changes  in  the  tension  or  rate  of  the  pulse.  Eosenbach  compares 
the  periodic  exhaustion  with  the  normal  pauses  for  rest  shown  by 
all  rhythmically  acting  systems.  The  different  phases  resemble 
natural  phenomena,  but  with  longer  intervals ;  the  period  of  breath- 
ing, for  example,  is  to  be  compared  with  a  respiration,  and  the 
period  of  apncea  with  the  short  pause  following  expiration.  The 
vagus  and  vaso-motor  centres  show  similar  variations.  The  ex- 
haustion of  the  brain  induces  sleep,  during  which  the  pupils  behave 
as  in  ordinary  slumber. 

The  centres  are  not  only  more  easily  exhausted,  requiring  longer 
rest,  but  their  irritability  is  reduced,  and  dyspnoea  comes  on  in 
spite  of  better  arterialization  of  the  blood  (which  involves  reduc- 
tion of  stimulus).  The  meaning  of  this  is  that  the  centre  is 
becoming  more  irritable  although  the  stimulus  is  lessening.  After 
a  time  the  normal  irritability  is  regained,  which  is  accompanied  by 
gentler  breathing  until  the  pause  occurs. 

The  author  holds  that  this  theory  differs  from  all  previous 
explanations  in  being  based,  not  on  periodic  variations  in  the 
amount  of  stimuli,  but  on  periodic  changes  in  the  irritability  of 
the  centre. 

Caizerques^  describes  the  case  of  a  man,  aged  64,  suffering  from 
mitral  disease,  in  the  course  of  which  he  laboured  for  some  days 
under  severe  dyspnoea,  which  was  replaced  afterwards  by  Cheyne- 
Stokes  respiration.  During  the  pause  the  intelligence  became 
very  cloudy,  but  the  patient  could  be  awakened  by  a  loud  noise  ; 
the  eyelids  drooped  and  the  pupils  contracted  in  this  phase. 
When  awakened  by  a  loud  noise  the  regular  periodicity  of  the 
breathing  was  for  a  time  arrested.  During  the  period  of 
breathing  the  eyes  were  opened,  and  the  face  bore  a  look  of 
anxiety.  The  pulse,  of  which  tracings  are  given,  was  more  fre- 
quent during  the  pause  than  during  the  breathing,  and  during  this 
latter  phase  it  was  extremely  irregular. 

After  death  it  was  found  that  there  was  mitral  incompetence 
with  extensive  arterial  atheroma,  more  especially  of  the  cerebral 
vessels,  with  congestion  of  the  kidneys  and  other  internal  organs. 

BulP  describes  an  interesting  case  in  which  the  patient,  belong- 
ing to  a  neurotic  family,  and  herself  the  victim  of  many  nervous 
symptoms,  was  seized,  when  20  years  old,  with  a  hysterical  affection 
of  the  breathing.  This  consisted  in  spasms  of  the  thoracic  muscles 
in  the  position  of  deep  inspiration  and  deep  expiration  alternately, 

^  Gazette  hehdomadaire  des  Sciences  mMicales  de  Montpellier,  tome  ii.  p.  337, 
1880. 
2  Norsk  Magazin  for  Lcegevidenskahen,  3  Raekke,  v.  Bind,  S.  165,  1880. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIEATION.  895 

the  former  lasting  as  long  as  forty  seconds,  and  the  latter  to  thirty- 
five  seconds.  This  condition  cannot  be  compared  with  Cheyne- 
Stokes  breathing,  as  the  only  point  of  resemblance  lies  in  the 
pauses. 

Blaise  and  Brousse,^  in  a  joint  communication  on  this  subject, 
give  a  brief  historical  review  of  previous  opinions  as  to  the  cause 
of  the  phenomenon,  and  then  pass  on  to  the  description  of  a  case  in 
which  it  occurred.  The  patient  in  this  case  was  a  man,  aged  88, 
suffering  from  bronchial  and  pulmonary  inflammation  associated 
with  pleurisy,  and  accompanied  by  renal  disease,  as  shown  by 
albuminuria  and  uraemia.  The  authors  watched  the  type  of 
breathing  under  consideration  for  ten  days ;  it  invariably  ceased 
during  sleep,  and  it  disappeared  finally  two  days  before  death. 
During  the  pauses  the  eyes  closed,  and  the  pupils  became  small 
and  reactionless ;  two  or  three  seconds  before  the  return  of  the 
breathing  the  pupils  dilated,  and  sometimes  executed  a  series  of 
oscillations  during  the  dyspnoea;  during  the  period  of  breathing 
they  were  sensible  to  light.  There  was  considerable  agitation  at 
the  height  of  the  dyspnoea,  at  which  time  consciousness  was  unim- 
paired, and  there  were  no  convulsions.  By  speaking  to  the  patient 
during  the  period  of  breathing  this  phase  could  be  prolonged  con- 
siderably. Sphygmographic  tracings  showed  during  the  pause  a 
fall  of  tension  and  an  increase  in  rate ;  during  the  respiratory 
period  the  reverse  occurred  along  with  irregularity  of  the  pulse. 
There  was  never  a  rise  of  tension  at  the  end  of  the  pause,  but,  on 
the  contrary,  sometimes  a  fall. 

After  an  excellent  description  of  this  case,  accompanied  by  ad- 
mirable tracings,  the  authors  give  a  brief  notice  of  another  case, 
under  the  care  of  Caizergues,  which  appears  to  be  that  previously 
referred  to. 

They  then  proceed  to  analyze  the  symptoms  attending  this 
phenomenon  with  great  care,  and  subsequently  criticise  the  views 
of  previous  observers,  to  which  they,  in  the  early  part  of  their 
paper,  had  called  attention.  This  brings  them  to  consider  the  view 
of  their  teacher  Grasset,  which  they  fully  expound.  According  to 
him,  the  dyspnoea  is  the  primordial  fact,  the  apnoea  being  merely 
a  consequence  of  it ;  and  the  type  of  breathing  is  a  symptom  of 
excitement.  The  anemia  of  the  medulla,  far  from  lowering, 
increases  the  irritability  of  that  organ.  In  ansemia  of  the  nerve- 
centres  such  phenomena  of  excitement  as  convulsions  are  common. 
The  diminution  of  the  blood-current  and  consequent  lessening  of 
the  nutrition  reduce  the  vitality  of  the  nerve-cells.  This  increases 
the  irritability,  but  at  the  same  time  tends  to  produce  weakness 
and  liability  to  exhaustion  of  the  nerve-centres.  In  short,  it  leads 
to  what  the  authors  call,  "that  peculiar  condition  which  the 
English  have  so  happily  termed  irritable  weakness."  This  gives 
the  key  to  the  causation  of  Cheyne-Stokes  breathing:  bulbar 
1  Montpellier  viedical,  tome  xliv.  p.  287,  1880. 


896  t)R   G.   A.   GIBSON   ON   THE  [APRIL 

anaemia  produces  greater  irritability  of  the  centres  which  it  con- 
tains ;  their  usual  excitant,  carbonic  acid,  acts  upon  them  with 
unaccustomed  intensity ;  the  breathing  assumes  the  character  of 
dyspnoea,  which  will  be  more  marked  if  excitement  of  the  vaso- 
motor centre  causes  constriction  of  the  arterioles,  thus  increasing 
the  bulbar  anaemia.  As  the  centres  are  easily  fatigued,  however, 
their  excitement  progressively  diminishes,  until  it  passes  away 
entirely,  whence  the  pause.  After  a  time,  the  nervous  elements 
repair  their  forces,  and  the  cycle  recommences. 

Franz,^  in  the  course  of  a  paper  on  artificial  respiration,  takes 
occasion  to  refer  to  the  observation  of  Leube,  pressed  by  Eosenbach 
in  opposition  to  Filehne's  theory,  that  during  the  pause  stimulation 
of  the  phrenic  nerves  has  no  influence  on  the  respiration.  He 
expresses  his  opinion  that  periodic  breathing  is  not  induced  by  a 
periodicity  in  the  respiratory  centre  apart  from  the  degree  of 
arterialization  of  the  blood,  but  that  the  origin  of  the  periodic 
event  is  a  certain  degree  of  venosity  of  the  blood.  He  states  that 
in  animals  under  the  influence  of  morphine  showing  periodic 
breathing,  faradization  of  the  phrenic  nerves,  when  the  trachea  is 
open,  causes  respiration,  which  he  holds  to  show  how  little  ground 
Eosenbach  has  for  citing  Leube's  and  his  own  observations  in 
opposition  to  the  theory  of  Filehne. 

Marckwald  and  Kronecker,^  as  the  result  of  further  observa- 
tions on  the  respiratory  movements,  state  that  they  have  fully 
confirmed  Traube's  observations,  that  the  occurrence  of  Cheyne- 
Stokes  respiration  is  connected  with  the  integrity  of  the  vagi,  for 
after  cutting  these  nerves  in  the  neck  the  phenomenon  never 
appeared,  and  if  present  before  section,  it  disappeared ;  in  fact, 
with  division  of  the  vagi,  all  regulation  of  the  respiration  was  lost. 

Hein'  asserts  that  neither  the  theory  of  Traube  nor  that  of 
Filehne  can  account  for  what  he  had  previously  described,  i.e., 
variations  in  the  state  of  consciousness,  and  he  believes  that  there 
must  be  the  same  cause  for  the  cerebral  and  bulbar  phenomena. 
He  therefore  again  states  his  theory.  He  quite  agrees  with  Biot 
that  cerebral  breathing  is  not  the  same  thing  as  Cheyne-Stokes 
respiration.  In  the  former  there  is  periodic  breathing  of  atypical 
form,  often  with  long  pauses,  sometimes  ascending  and  descending 
in  character,  and  having  no  constant  relation  between  the  eye  and 
breath  symptoms ;  but  if  the  eye  signs  are  present,  the  pupils  are 
wide  during  the  breathing  and  narrow  in  the  pause.  It  occurs  in 
many  diseases,  and  the  prognosis  is  not  always  unfavourable. 

Periodic  breathing  of  the  Cheyne-Stokes  type  he  holds  to  be,  as 
a  rule,  associated  with  a  state  of  unconsciousness.  Sometimes 
consciousness  returns  during  the  period  of  breathing,  but  is  absent 
in  the  pause,  and  if  this  is  the  case,  the  consciousness  and  the 

1  Archivfiir  Physiologic,  Jahrgang  1880,  S.  398. 

2  Ibid.,  S.  441. 

3  Deutsches  Archivfiir  klinische  Medicin.,  xxvii.  Band,  S.  569,  1880. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  897 

breathing  reappear  simultaneously.  If  pupillary  variations  are  to 
be  seen,  the  pupils  are  of  middle  size  during  respiration,  become 
narrower  during  the  descending  phase,  and  are  small  and  insensitive 
during  the  pause,  gradually  widening  with  the  ascending  respira- 
tions. If  the  vaso-motor  nerves  are  affected,  there  is  higher 
arterial  tension  during  the  respiratory  period.  This  may  pass 
from  regular  Cheyne-Stokes  respiration  into  the  atypical  form  at 
times.  The  type  of  the  respiration  may  be  due  to  periodic  varia- 
tions in  activity  of  the  respiratory  centre  alone  or  associated  with 
similar  variations  of  other  centres. 

Lowit,^  from  a  careful  study  of  tracings  obtained  by  means  of 
the  polygraph  in  a  case  of  Cheyne-Stokes  respiration,  forms  the 
opinion  that  this  symptom  is  not  to  be  regarded  as  identical  with 
the  periodic  breathing  produced  experimentally  by  Filehne.  He 
holds  that  Cheyne-Stokes  breathing  does  not  depend  upon  varia- 
tions in  the  condition  of  the  circulation,  but  upon  fluctuations  in 
the  activity  of  the  nervous  mechanism  of  the  breathing,  such  as 
changes  in  the  irritability  of  the  respiratory  centre  from  exhaustion 
and  recovery.  The  irritability  of  the  respiratory  centre  alters 
under  conditions  not  yet  perfectly  known,  but  no  doubt  belonging 
to  the  processes  of  tissue  change.  He  regards  this  as  the  cause  of 
the  symptom. 

Winternitz,^  writing  of  Cheyne-Stokes  respiration  in  children, 
describes  a  case  in  which  the  patient,  who  was  a  highly  hysterical 
girl,  was  thrown  into  a  state  of  great  nervous  irritability  after  a 
painful  operation  on  the  teeth,  and  in  this  condition  developed 
the  type  of  breathing  in  question.  It  was  present  during  a  period 
of  thirty-six  hours,  and  then  disappeared.  Another  case  described 
is  that  of  a  little  boy  suffering  from  catarrh  of  the  nose  and  throat, 
with  vomiting  and  diarrhoea,  in  whom  the  Cheyne-Stokes  breath- 
ing was  present  for  twelve  hours,  until  the  patient  improved. 
During  the  pauses  the  pupils  were  contracted.  He  is  of  opinion 
that  in  such  a  case  the  determination  of  blood  to  the  intestines, 
acting  on  a  delicate  and  nervous  organism,  caused  anaemia  of  the 
medulla,  and  thus  induced  the  Cheyne-Stokes  breathing.  He 
suggests  mechanical  compression  of  the  abdomen  in  similar  cases, 
but  says  he  omitted  it  in  his  own. 

Solokow  and  Luchsinger,  in  giving  the  results  of  a  careful  series 
of  experiments,  contribute  some  interesting  observations^  to  this 
subject.  They  state  that  when  frogs,  which  have  been  immersed 
for  some  hours  in  water,  begin  to  recover  from  their  stupor,  they 
show  the  Cheyne-Stokes  phenomenon;  that  when  frogs  in  winter 
are  exposed  to  the  action  of  heat,  and  the  aorta  is  clamped,  the 
same  phenomenon  occurs  on  the  removal  of  the  clamp  and  on  its 

1  Prager  medicinische  Wochenschrift,  v.  Band,  SS.  461,  473,  481,  u.  499, 1880. 

2  Archiv  fiir  Kinderheilkunde,  i.  Band,  S.  142,  1880. 

'  Archiv  fiir  die  gesammte  Physiologie  des  Menschen  und  der  Thiere,  xxiii. 
Band,  S.  283,  1880. 

EDINBURGH   MED.   JOURN.,   VOL.   XXXIV. — NO.    X.  5x 


898  DR   G.   A.   GIBSON   ON   THE  [APRIL 

being  again  replaced ;  that  the  periodic  respiration  is  also  seen  on 
clamping  the  aorta,  after  cutting  the  cord  in  the  neck  and  destroy- 
ing the  spinal  cord  below  that  point,  showing  that  it  is  quite 
independent  of  conditions  of  blood-pressure ;  that  its  occurrence 
is  not  affected  by  any  changes  of  pressure,  or  by  the  substitution 
of  saline  solutions  in  place  of  blood ;  and  that  the  vagi  are  not 
necessary  for  its  appearance.  They  state  that  the  conditions  of 
periodicity  are  no  other  than  such  as  are  developed  in  every  tissue, 
with  growing  asphyxia.  Describing  the  administration  of  picro- 
toxin  hypodermically  during  ether  narcosis,  they  mention  that  the 
Cheyne-Stokes  respiration  and  convulsions  occurred  synchron- 
ously, and  that  on  the  administration  of  more  ether  the  convul- 
sions ceased  while  the  periodic  breathing  went  on.  They  compare 
the  phenomenon  with  the  periodicity  of  lymph  hearts  as  seen  by 
themselves ;  with  the  periodicity  of  blood  hearts  described  by 
Luciani ;  with  the  periodicity  of  the  heart  observed  by  Eosenbach 
when  a  supply  of  defibrinated  blood  has  been  allowed  to  circulate 
too  long  and  has  lost  its  colour  ;  and  with  the  occurrence  of  the 
contractions  of  exhausted  Medusae  in  groups.  They  conclude  that 
the  observations  of  comparative  physiology  as  well  as  the  results 
of  experimental  analysis  agree  in  showing  the  conditions  of  this 
grouping  of  movements.  Increase  of  stimulus  and  decrease  of 
elasticity  show  themselves  to  be  the  important  factors.  It  may 
without  hesitation  be  supposed  that  the  cause  of  the  periodicity 
is  to  be  sought  in  the  lessened  elasticity  and  greater  exhaustibility 
of  the  organ,  and  this  view  is  supported  by  direct  observation. 
In  answer  to  Filehne's  question,^  why  the  exhaustion  does  not 
follow  each  respiration,  instead  of  showing  itself  after  a  series  of 
respirations,  they  reply  that  the  irritability  of  a  nervous  organ 
will  rise  when  after  repose  it  is  awakened  to  activity  by  stimuli, 
but  it  will  sink  if  the  activity  has  lasted  too  long.  They  refer  to 
the  observations  of  Kronecker  and  Marckwald,  already  mentioned, 
as  being  entirely  analogous  to  the  phenomena  of  Cheyne-Stokes 
respiration. 

O'NeilP  lays  stress  on  the  fact  that  the  respiratory  pause  may 
be  present  without  any  ascending  and  descending  phenomena,  but 
is  not  prepared  to  say  that  arrests  of  this  kind  should  be  classed 
as  Cheyne-Stokes  respiration.  He  mentions  the  case  of  a  lady 
suffering  from  chronic  bronchitis  and  emphysema,  with  dilatation 
and  hypertrophy  of  the  heart,  in  whom  arrests  of  respiration 
appeared,  after  an  exacerbation  of  her  pulmonary  troubles,  accom- 
panied by  general  anasarca.  The  arrests  of  breathing  disappeared 
when  the  chest  improved  and  the  dropsy  passed  away.  He 
describes  a  case  in  which  there  was  difficulty  of  articulation  and 
deglutition  along  with  Cheyne-Stokes  breathing,  and  he  supposes 
there  was  an  affection  of  the  medulla  as  well  as  of  other  nervous 

1  Ueber  des  Cheyne-Stokes'sche  Athmungsphanoimen,  S.  17,  1874. 
*  Lancet^  vol.  ii.  for  1880,  p.  691, 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  899 

centres.  In  this  case  the  pauses  appeared  after  the  use  of  chloral. 
O'Neill  states  that  in  two  cases  nitrite  of  amyl  produced  no  effect, 
but  that  another  patient  suffering  from  renal  disease,  accompanied 
by  Cheyne-Stokes  respiration,  felt  much  relief  from  this  drug, 
which  on  several  occasions  "restored  and  reinvigorated  the  breath- 
ing when  it  was  about  to  cease." 

Lereboullet  gives  an  excellent  summary  of  the  various  views 
held  by  the  principal  writers  on  the  phenomena  of  Cheyne-Stokes 
respiration.^  He  is  evidently  of  opinion  that  Filehne's  investiga- 
tions have  tended  to  show  that  the  primary  cause  of  the  symptom 
is  an  affection  of  the  vaso-motor  centre,  while  the  respiratory  centre 
is  only  concerned  in  its  production  in  a  secondary  manner.  Lere- 
boullet adds  no  original  observations  of  his  own  to  the  subject 
with  which  he  deals. 

Eosenbach*  gives  another  critical  study  of  the  phenomena  of 
Cheyne-Stokes  respiration,  in  which  he  asserts  that  to  this  type  of 
breathing  are  to  be  referred  all  forms  of  respiration  in  which  the 
respiration  is  intermittent,  or  there  is  any  periodic  change  in  the 
depth  of  the  inspirations.  He  therefore  includes  the  effects  of 
morphine  in  the  group  of  periodic  changes  of  respiration,  and 
points  out  that  as  this  drug  lowers  all  the  vital  centres  there  are 
usually  changes  in  the  functions  linked  with  the  respiration.  He 
then  refers  to  the  various  symptoms  associated  with  Cheyne-Stokes 
respiration,  and  holds  that  any  valid  theory  must  account  for  all 
of  them.  He  goes  on  to  state  that  the  common  characteristic  of 
these  phenomena  is  an  alternation  of  activity  and  repose,  which 
belongs  to  all  nervous  processes,  and  which  is  present  in  this  case 
with  longer  periods  of  repose.  In  addition,  he  points  out  how  far 
reaching  is  the  analogy  between  the  phenomena  of  Cheyne-Stokes 
respiration  and  the  normal  physiological  processes.  He  ends  his 
contribution  by  stating  the  differences  between  the  theory  of 
Traube  and  that  which  he  proposed  as  follows  : — 1.  His  own  theory 
is  wider,  and  is  concerned  with  symptoms  unknown  or  insuffi- 
ciently appreciated  before ;  2.  It  takes  little  account  of  fatigue, 
and  looks  to  the  excitability  and  non-excitability  of  centres ;  and 
3.  It  holds  the  different  phenomena  to  be  independent  of  the 
changes  of  the  circulation. 

A  somewhat  warm  discussion  took  place  between  Filehne  ^  and 
Rosenbach  *  in  regard  to  their  respective  theories,  in  which  no  new 
facts  or  views  were  advanced  on  either  side.  The  only  points  of 
interest  in  Filehne's  two  articles  are  contained  in  his  allegation 
that  Rosenbach's  theory  is  not  a  new  one,  but  merely  a  modifica- 
tion of  Traube's  exhaustion  hypothesis,  and  in  his  statement  that 

1  Dictionnaire  encyclop^dique  des  sciences  m^dicales,  Premiere  s^rie,  tome 
XXV.,  1880. 

2  Deutsche  medicinische  Wochfinschrift,  vii.  Jahrgang,  SS.  27,  u.  39,  1881. 
'  Zeitschrift  fiir  klinische  Medicin,  ii.  Band,  SS.  255  u.  472,  1881. 

*  Ibid.,  S.  713. 


900  PHENOMENA  IN   CHEYNE-STOKES   RESPIRATION.  [APRIL 

its  author  has  only  supported  it  by  purely  speculative  reasoning — 
a  statement  full  of  unconscious  irony  against  its  maker. 
Eosenbach's  reply  to  these  strictures  is  a  strong  refutation  of  the 
charges  brought  against  his  views,  in  which  he  has  unfortunately 
followed  the  polemical  style  of  his  critic. 

(To  be  continued.) 


IIL-NOTE  ON  SOME  ANOMALOUS  CASES  OF  SEPARATION 
AND  EXPULSION  OF  THE  PLACENTA  BEFORE  THE 
BIRTH  OF  THE  CHILD. 

By  D.  Berry  Hart,  M.D.,  F.R.C.P.  Ed.,  F.R.S.  Ed.,  Lecturer  on  Midwifery, 
Surgeons'  Hall,  Edinburgh. 

{Bead  before  the  Edinburgh  Obstetrical  Society,  ISth  February  1889.) 

For  some  time  past  anomalous  separations  of  the  placenta  have 
occupied  my  thoughts,  but  I  intended  to  defer  special  investigation 
of  these  till  opportunity  of  studying  them  in  the  living  woman 
occurred.  A  recent  paper  by  Dr  Helme  has  induced  me,  how- 
ever, to  bring  this  subject  before  the  Fellows,  inasmuch  as  both  in 
Dr  Helme's  paper  and  in  the  discussion  following,  the  opinion  was 
unanimously  expressed  that  the  case  recorded  was  against  my 
view  of  placental  separation. 

The  anomalous  separations  I  purpose  bringing  before  you  to- 
night are  as  follows : — 

I,  Cases  where  the  Placenta  is  separated  and  expelled 
IN  Twin  Births  in  an  anomalous  manner. 

II.  Cases  where  the  normally  situated  Placenta  is  separ- 
ated AND  expelled  IN  A  SiNGLE  BiRTH  BEFORE  THE  ChILD  IS 
BORN. 

I.  Cases  where  the  Placenta  is  separated  and  expelled 
IN  Twin  Births  in  an  anomalous  manner. 

In  a  twin  labour  we  may  have  the  following  phenomena  as 
regards  separation  of  the  placenta  : — 

1.  Both  placentae  may  he  separated  and  expelled  after  the  birth  of 
both  children. 

2.  Both  placentce  may  be  separated  and  expelled  before  the  birth  of 
the  second  child. 

3.  The  placenta  of  the  first  born  child  may  be  separated  and  expelled 
after  the  birth  of  the  first  child  and  before  the  birth  of  the  second. 

4.  The  placenta  of  the  second  child  may  be  expelled  after  the  birth 
of  the  first,  the  second  being  still-born. 

5.  Both  children  being  born,  the  placenta  of  the  second  may  be  born 
before  that  of  the  first. 

6.  Both  placentae  may  be  expelled  before  the  birth  of  the  children. 
In  1  we  have  the  normal  third  stage. 


1889.]   NOTE  ON  THE  SEPARATION  OF  THE  PLACENTA,  ETC.    901 

In  2  and  3  the  difference  is  due  to  the  fact  that  in  the  former 
there  is  only  one  placenta,  in  the  latter  two. 

In  4  and  6  we  have  cases  analogous  to  prolapsus  placentae. 

The  two  forms  for  discussion  under  head  I.  are  3  and  5  ;  4  and 
6  come  under  head  II. 

3.  The  placenta  of  the  first  horn  child  may  he  separated  and  ex- 
pelled after  the  hirth  of  the  first  child,  and  hefore  the  hirth  of  the 
second. 

Den  man  gives  two  cases  of  this : — 

1.  C.  J. ;  twins.  The  placenta  of  the  first  child  was  expelled 
immediately.  The  feet  of  the  second  were  then  found  in  the 
vagina  and  brought  down.  There  was  not  the  slightest  haemor- 
rhage.    The  first  was  born  alive,  the  second  putrid. 

2.  M.  C. ;  twins.  The  placenta  of  the  first  was  expelled  before 
the  birth  of  the  second,  without  hcemorrhage.  Both  children  were 
born  alive  at  the  full  period. 

We  have  here,  therefore,  a  remarkable  phenomenon,  viz.,  the 
separation  of  a  placenta  while  the  uterus  contains  a  second  child 
and  has  a  large  uterine  area.  After  the  first  child  is  born,  the 
area  of  its  placenta  cannot  be  4  inches  by  4  inches.  However  the 
placenta  separates  in  such,  it  is  at  an  area  comparatively  large,  and 
also  without  the  aid  of  blood  effusion.  It  will  of  course  be  asked, 
Does  the  view  propounded  by  me  explain  such  cases  ?  To  this  I 
answer,  that  nothing  in  these  cases  militates  against  my  view,  my 
caution  being  dictated  by  the  circumstance  that  we  have  not  all 
the  facts  of  such  before  us.  My  view,  put  in  the  most  general 
manner,  does  not  assert  that  any  area  is  required  for  the  separation 
of  a  placenta.  All  that  is  necessary  is  a  disproportion  between 
placental  area  and  placental  site.  When  in  twin  cases  the  first  child 
is  born  alive,  as  happened  in  the  second  case  narrated,  we  have 
the  two  placentae  under  different  conditions.  That  of  the  child 
unborn  has  its  foetal  circulation  intact  and  its  maternal  only  par- 
tially obliterated ;  while,  on  the  other  hand,  that  of  the  born  child 
has  its  fcetal  circulation  stopped  entirely  and  its  maternal  circula- 
tion as  in  the  former.  It  does  not,  therefore,  respond  to  the 
increase  in  site  following  a  pain,  becomes  separated,  and  then 
expelled.  This,  I  believe,  will  be  found  to  be  the  essential 
mechanism. 

5.  Both  children  heing  horn,  the  placenta  of  the  second  may  he  horn 
hefore  that  of  the  first. 

An  interesting  case  of  this  has  been  recently  recorded  by  Dr 
Helme.  It  is  briefly  as  follows  :  The  first  child  was  born  spon- 
taneously, while  the  second  required  its  bag  of  membranes  ruptured, 
and  had  spina  bifida.  The  cord  was  not  pulsating  when  it  was 
born,  and  no  respirations  were  made. 

During  the  third  stage  the  uterus  contracted  badly  and  relaxed 
considerably.  Ultimately  the  lower  placenta  was  expelled,  but 
the  upper  was  only  partially  separated,  and  was  ultimately  re- 


902  DR  D.   BEERY   HAET'S    NOTE   ON  [APRIL 

moved  manually.  Dr  Helme,  by  passing  his  hand  in  early  in  the 
third  stage,  found  the  placentae  both  unseparated,  even  after  con- 
traction and  relaxation  had  occurred. 

Dr  Helme  urges — 1.  That  the  lower  placenta  was  separated  and 
expelled  by  uterine  pains,  i.e.,  by  diminution  of  area.  2.  That  the 
placenta  of  the  still-born  child  had  its  foetal  half  not  a  bloodless 
structure,  as  it  did  not  aspirate  the  blood  there.  3.  That  the 
placenta  of  the  living  child  was  not  expelled,  although  he  believes 
all  the  conditions  I  demand  for  such  expulsion  were  present. 

Dr  Helme's  facts  bear  evidence  of  accuracy,  but  he  has  built 
upon  them  a  superstructure  of  criticism  which  they  cannot  bear. 
Thus,  1.  The  second  child  was  dead ;  at  any  rate  its  cord  was  not 
pulsating,  and  it  did  not  breathe.  Yet  Dr  Helme  makes  the  re- 
markable statement  that  its  foetal  portion  was  not  a  "  bloodless 
structure,"  inasmuch  as  it  did  not  breathe.  Dr  Helme  evidently 
thinks  that  the  only  way  the  foetal  portion  of  the  placenta  is  ren- 
dered bloodless  is  by  the  child's  aspiration.  The  death  of  the 
child  does  the  same,  and  consequently  this  placenta  had  the  con- 
ditions as  to  circulation  my  view  demands.^ 

The  placenta  of  the  living  child  was  removed  manually,  as  its 
upper  portion  was  unseparated.  This  means,  of  course,  that  it  was 
adherent  there. 

Dr  Helme,  indeed,  is  in  a  dilemma  about  this  upper  placenta. 
The  diminution  of  area  was,  according  to  him,  sufficient  to  separate 
the  lower  placenta ;  then  why  not  the  upper  one  too  ?  If  Dr 
Helme  wishes  to  criticise,  he  should  certainly  criticise  the  diminu- 
tion in  area  theory. 

The  fact  is  that  Dr  Helme  has  made  a  perfectly  simple  case  com- 
plicated. The  explanation  I  would  give  is  as  follows: — During  the 
relaxations  following  the  pains,  the  lower  placenta  and  lower  part 
of  the  upper  placenta  became  separated.  As  during  the  third  stage 
relaxation  was  so  prominent  and  contraction  so  feeble,  I  am  indeed 
disappointed  not  to  have  had  Dr  Helme's  support  instead  of  his 
adverse  opinion.  The  part  of  the  placenta  not  separated  was  the 
part  adherent ;  for,  whatever  may  be  said  to  the  contrary,  a  placenta 
separated  manually  is  an  adherent  placenta,  and  Dr  Helme  knows 
his  work  too  well  to  separate  manually  a  non-adherent  placenta.  The 
two  placentas  at  a  certain  stage  were,  therefore,  exactly  analogous 
to  an  ordinary  placenta  with  its  lower  part  separated  and  its  upper 
adherent.  The  expulsion  of  the  lower  one  would  not  have  occurred 
had  the  placenta  been  a  single  one. 

1  Dr  Helme  has  further  misunderstood  my  view.  During  the  normal  third 
stage  I  consider  that  the  placenta  does  not  follow  up  the  expansion  of  its  site 
following  a  pain  ;  but  1  do  not  assert  that  the  absence  of  blood  in  the  foetal 
portion  is  one  of  the  factors.  It  is  the  absence  of  the  active  foetal  circulation 
due  to  the  foetal  heart.  Every  one  knows  that  the  cord  may  be  tied  imme- 
diately after  birth  without  materially  hindering  the  Third  Stage,  and  therefore 
Dr  Helme's  criticism,  besides  being  erroneoiis  on  this  point,  is  unnecessary. 


1889.]  THE   SEPAEATION   OF  THE   PLACENTA,  ETC.  903 

II.  Cases  where  the  Placenta  is  separated  and  expelled 
IN  A  Single  Birth  before  the  Child  is  born. 

This  so-called  prolapsus  placentae  is  one  of  the  most  remarkable 
phenomena  connected  with  labour.  That  the  normally  situated 
placenta  with  its  membranes  should  be  expelled  entire  without 
haemorrhage,  and  before  the  child  is  born,  in  a  full  time  labour, 
seems  incredible ;  yet  fully  authenticated  cases  have  been  noted, 
and  place  the  matter  beyond  doubt.  In  a  recent  paper,  Miinch- 
meyer  gives  the  history  of  the  known  cases,  and  describes  a  case 
with  valuable  details  occurring  in  the  Dresden  klinik.  His  case, 
so  far  as  it  bears  on  the  present  question,  is  briefly  as  follows : — 
The  patient  had  a  deformed  pelvis  (rickety  and  universally  con- 
tracted :  C.V.,  3-3^  inches).  She  was  in  labour  for  some  time,  and 
at  2  A.M.  the  foetal  heart-sounds  were  not  heard.  Five  and  a  half 
hours  after  this  the  placenta  and  membranes  presented  at  the 
vulva,  and  were  removed  intact.  The  child  was  turned,  and  born 
with  great  difficulty. 

The  question  to  be  settled  here  is  whether  the  dead  child  was 
the  result  or  cause  of  the  premature  separation  of  the  placenta. 
That  neither  blood  effusion  nor  diminution  of  area  caused  the 
placental  separation  is  evident.  I  would  urge  that  the  placental 
separation  and  expulsion  in  cases  like  Munchmeyer's  are  brought 
about  as  follows : — As  the  result  of  the  prolonged  labour  the  child 
dies  ;  this  cuts  off  the  fcetal  circulation.  The  intervillous  circula- 
tion is  also  diminished  by  prolonged  uterine  retraction,  and  thus 
we  have  the  placenta  prevented  from  following  up  the  expansion 
of  its  site  after  the  pain  dies  off,  i.e.,  we  get  a  disproportion  between 
the  placental  site  and  placental  area,  and  separation  as  the 
result.  The  conditions  are  the  same  as  in  the  normal  third  stage, 
except  that  the  intervillous  circulation  is  less  diminished.  The 
length  of  the  labour  after  the  child  is  dead  is  of  importance,  as 
this  means  more  marked  uterine  retraction  and  greater  diminution 
of  the  intervillous  circulation. 

It  will  be  advisable,  in  conclusion,  to  restate  my  views  on  the 
subject  of  the  separation  of  placenta  and  membranes,  so  as  to  give 
definiteness  to  the  discussion.  I  hold  that  the  placenta  does  not 
separate  as  the  result  of  diminution  of  area  of  the  placental  site. 
In  order  to  get  separation,  there  must  be  a  disproportion  between 
placental  site  and  placental  area.  In  placenta  praevia  the  expan- 
sion in  area  of  the  lower  uterine  segment  not  being  participated  in 
by  placenta,  gives  the  necessary  disproportion.  In  the  third  stage 
the  disproportion  is  brought  about  as  follows : — 

1.  The  placental  site  increases  slightly  as  the  pain  dies  off. 

2.  The  placenta  does  not  respond  to  this,  as  its  foetal  and  inter- 
villous circulation  are  cut  off. 

I  may  add  that  no  area  of  diminution  is  necessary  for  separa- 
tion, but  merely  disproportion  between  the  placental  site  and  area. 
In  this  way  the  anomalous  separation  can  also  be  cleared  up. 


904         note  on  the  separation  of  the  placenta,  etc.      [april 

Bibliography. 

Collins. — A  Practical  Treatise  on  Midwifery,  London,  1835. 
Helme.— "The  Physiology  of  the  Third  Stage  of   Labour,"  Bd. 

Med.  Jour.,  January  1889. 
Munchmeyer. — "  Uber  den  Vorfall  der  Nachgeburt  bei  regelmas- 

sigem  Sitze  derselben,  Arch.fiir  Gyndk,  Bd.  33,  Hft.  3. 
Simpson,  Sir  J.  Y. — Collected  Works,  vol.  i.  p.  230. 


IV.— A  CASE   OF   PRIMARY  SARCOMA   OF   LIVER;     RAPID 
PROGRESS  ;  DEATH  ;  AUTOPSY. 

By  W.  Scott  Lang,  F.R.C.S.E.,  Lecturer  on  Surgery. 

M.  B.,  a  female,  aged  57,  first  came  under  my  care  on  26th 
November  1888.  She  complained  of  a  swelling  or  lump  in  the 
abdomen.  The  patient's  history  of  her  case  was  to  the  effect  that 
she  had  been  losing  flesh  for  some  little  time  before  applying  for 
advice.  She  stated  that  her  illness  began  about  two  months  pre- 
viously by  severe  pain  below  the  right  mamma.  She  applied  a 
mustard  poultice,  which  gave  relief,  but  the  pain  returned  again. 
She  had  first  noticed  a  swelling  below  the  margin  of  the  right 
costal  cartilages  about  the  mammillary  line.  The  swelling  next 
passed  across  towards  the  epigastrium,  and  then  more  towards  the 
umbilicus.  There  was  not  constant  pain,  but  a  disagreeable, 
uneasy  feeling  which  was  most  marked  when  she  lay  on  her  back. 
Her  appetite  was  diminished,  and  after  taking  food  she  felt  swollen 
and  uncomfortable.  There  was  no  difficulty  of  breathing;  no 
sickness  nor  vomiting.  The  bowels  acted  regularly,  and  the  faeces 
were  normal  in  colour. 

Physical  Examination. — The  abdomen  was  somewhat  distended, 
and  slight  bulging  could  be  observed  at  the  flanks.  A  large  pro- 
jection with  two  rounded  summits  could  be  seen  in  the  right 
hypochondriac,  epigastric,  and  umbilical  regions. 

Palpation  elicited  slight  tenderness.  The  swellings  were  dis- 
tinctly felt  to  be  rounded  and  smooth,  probably  connected.  The 
projection  in  the  epigastrium  could  be  traced  farther  to  the  right 
than  to  the  left.  On  the  right  it  was  lost  in  the  hypochondrium, 
and  on  the  left  it  could  be  traced  for  two  inches  beyond  the 
middle  line.  Below  this  there  was  a  depression.  Still  lower 
down  and  immediately  to  the  right  of  the  umbilicus  there  was 
another  swelling,  rounded,  hard,  and  circumscribed.  Later  on 
another  slight  prominence  could  be  felt  to  the  right  of  this  on 
deep  palpation.  The  mass  reached  downwards  to  within  about 
one  inch  of  the  iliac  crest.  The  whole  mass  moved  upwards  and 
downwards  with  the  diaphragm  in  respiration.  No  fluctuation 
could  be  detected.     No  enlarged  glands  were  felt. 

Percussion. — The  note  was  dull  over  the  epigastric  swelling. 


188!).]  A    CASE   OF    PlIIMAKY    SAKGOMA    OF    LIVER.  905 

Over  the  umbilical  swelling  the  note  was  impaired,  but  not  com- 
pletely dull  as  in  the  epigastrium.  There  was  dulness  in  the 
right  lumbar  region  round  to  the  spinal  column.  In  the  mid- 
axillary  line  the  dulness  extended  to  the  iliac  crest.  The  note 
was  continuously  dull  from  the  right  hypochondriac  region  to  the 
epigastric  swelling. 

No  enlargement  of  the  spleen  could  be  made  out. 

Urine  about  30  ounces  daily,  s.g.  1024;  no  albumen,  blood,  nor 
sugar. 

Mr  Duncan  kindly  admitted  the  patient  to  the  Royal  Infirmary 
under  his  care.  She  was  subsequently  transferred  to  the  care  of 
I)r  Brakenridge,  and  I  am  indebted  to  Mr  Abernethy,  M.B.,  CM., 
resident  surgeon,  and  to  Mr  Boyd,  M.B.,  CM.,  resident  physician, 
for  the  use  of  valuable  notes  of  the  case. 

Subsequent  Progress. — The  patient  returned  home  on  18th 
December  1888.  She  grew  rapidly  worse,  and  died  exhausted  on 
4th  February  1889.  For  some  time  before  death  she  lay  persist- 
ently on  the  left  side,  and  refused  to  be  moved  from  that  attitude. 

Autopsy. — I  performed  the  post-mortem  examination  on  6th 
February.  The  body  was  much  emaciated.  There  was  marked 
ascites ;  no  general  dropsy ;  no  jaundice.  The  abdomen  having 
been  opened,  a  large  quantity  of  straw-coloured  fluid  was  removed. 
The  liver  at  once  presented  itself  with  several  large  yellowish- 
white  nodular  masses  visible.  It  was  removed  without  opening 
the  alimentary  canal.  There  were  some  slight  adhesions  to  the 
duodenum ;  when  removed  it  weighed  13|  lbs.  It  was  evidently 
almost  entirely  filled  with  large  rounded  masses  of  new  growth. 
These  masses,  where  they  were  visible  at  the  surface,  were  soft 
and  semi-fluctuating.  One  mass,  on  the  posterior  aspect,  burst 
during  removal,  and  thick,  caseous,  purulent  material  escaped.  The 
other  organs  were  unaffected.  The  liver  is  now  in  the  Museum 
of  the  Royal  College  of  Surgeons,  Edinburgh.  The  growth  proved 
to  be  round-celled  sarcoma,  undergoing  degeneration  and  caseation. 


v.— CASE   OF  INGUINAL   HERNIA   IN   A  FEMALE   CHILD, 
WITH  CURIOUS  COMPLICATIONS. 

By  J.  Craig  Balfour,  L.R.C.P.  and  S.E.,  Redboume,  Lincolnshire. 

On  Wednesday,  the  30th  January,  I  received  a  letter  from  one 
of  my  patients  asking  me  to  call  and  see  her  youngest  cliild,  a  girl 
about  two  years  and  a  half  old,  as  they  had  discovered  a  "  swelling 
between  her  legs,"  which  appeared  to  cause  her  a  good  deal  of  pain. 
On  my  arrival  I  was  informed  that  she  had  been  very  restless,  and 
had  shown  great  disinclination  to  be  moved  or  touched,  at  first 
attributed  to  feverishness  arising  from  a  slight  cold  and  sore  throat 
which  had  troubled  her  for  some  days ;  on  undressing  her  at  night, 

EDINBURGH   MED.    JOURN..   VOL.    XXXIV.— NO.    X.  5  Y 


906  MR   J.   CRAIG   BALFOUR   ON   A   CASE   OF  [APRIL 

however,  the  nurse  said  she  noticed  a  swelling  between  the  legs, 
which  she  had  not  seen  before.  The  child  had  had  a  powder  on 
the  Monday  night,  and  the  bowels  had  been  moved  on  Tuesday 
morning  but  slightly,  and  described  as  looking  more  like  a  natural 
motion  than  the  result  of  medicine.  Tliere  was  said  to  have  been 
no  straining  in  any  way,  nor  had  she  had  any  violent  cough.  Upon 
examining  her,  I  found  the  left  labium  majus  much  swollen  and 
inflamed ;  the  swelling  continued  upwards,  forming  a  sort  of  ridge, 
extending  as  far  as  the  abdominal  ring.  Though  the  patient  was 
too  young  to  cough  when  told,  etc.,  yet  when  she  cried  I  was  able 
to  feel  the  impulse,  and  to  decide  that  at  least  part  of  the  swelling 
was  due  to  an  inguinal  hernia.  This  I  reduced,  but  after  the  re- 
duction there  was  still  considerable  hardness  and  swelling  of  the 
labium,  especially  over  the  lower  part. 

The  child  was  put  on  milk  diet,  and  the  hips  placed  on  a  pillow, 
in  order  to  keep  the  pelvis  higher  than  the  abdomen,  and  so  assist 
in  preventing  the  hernia  from  again  descending.  Cold  cloths  were 
ordered  to  be  applied  over  the  labium,  to  which  the  inflammation 
was  confined,  not  extending  upwards  at  all.  The  next  day  I  saw 
the  child  along  with  Dr  George  of  Kirton-Lindsey. 

The  hernia  had  come  down  during  the  night  when  she  had  been 
moved,  and  there  was  still  great  inflammation  of  the  labium,  which 
at  its  lower  part  was  very  tense  and  tender  to  the  touch,  and  looked 
as  if  an  abscess  were  forming.  There  was  no  tenderness  of  the 
abdomen,  nor  any  tympanitis  or  sickness,  but  the  bowels  had  not 
been  moved  since  the  Tuesday  morning.  Her  temperature  was 
103°'4 ;  she  had  passed  water  freely  during  the  night. 

Poultices  wer(3  ordered  to  be  applied  over  the  inflamed  part,  the 
position  to  be  continued,  as  also  the  milk  diet,  and  a  small  dose  of 
effervescent  citrate  of  magnesia  to  be  given  night  and  morning  ;  no 
attempt  to  be  made  to  reduce  hernia. 

On  the  1st  February  she  was  in  much  the  same  condition  ;  her 
temperature  had  come  down  to  102°"4,  but  there  was  an  erythe- 
matous blush  over  the  left  hip,  and  a  large  bleb  filled  with  serum 
had  formed  at  the  lower  part  of  labium,  and  extended  upwards 
between  it  and  the  leg  for  about  two  inches.  This  was  let  out,  and 
everything  contitmed  as  before. 

On  the  2nd  February  the  temperature  and  general  condition  were 
unaltered,  but  there  was  slight  tenderness  over  the  neck  of  the  sac ; 
the  erythematous  blush  had  spread  over  both  hips  and  lower  part 
of  abdomen,  and  a  slough  appeared  to  be  forming  where  the  large 
bleb  had  been. 

On  the  3rd  Dr  George  again  kindly  saw  the  little  patient  along 
with  me.  The  erythema  was  only  showing  in  small  patches,  nor 
was  there  so  much  tenderness  over  the  neck  of  the  sac.  The  bowels 
had  not  yet  been  moved  ;  and  Dr  George  advised  that,  if  no  action 
took  place  within  a  day  or  two,  a  small  enema  of  glycerine  should 
be  given,  everything  else  to  be  continued  as  before,  and  the  case  to 


1889.]  INGUINAL   HERNIA  IN   A   FEMALE   CHILD.  907 

be  carefully  watched.  However,  we  were  able  to  dispense  with  the 
enema,  as  the  bowels  moved  soon  after  we  left  on  the  Sunday  (3rd). 
They  were  again  moved  on  the  Monday,  and  the  hernia  was  found 
to  have  been  spontaneously  reduced. 

The  bowels  have  continued  to  act  almost  daily,  and  the  hernia 
has  kept  up.  The  upper  part  of  left  leg  where  the  erythema  first 
appeared  was  somewhat  swollen,  and  I  ordered  it  to  be  gently  rubbed, 
and  straightened  from  the  flexed  position  in  which  she  generally 
kept  it,  as  the  tendons  were  becoming  contracted.  The  slough  I 
touched  with  nitrate  of  silver,  and  ordered  the  poultices  to  be  con- 
tinued. It  soon  began  to  separate,  leaving  a  deep  and  ugly  ulcer, 
with  edges  very  much  undermined  ;  it  was  dressed  and  washed  with 
carbolic  lotion,  and  did  not  seem  to  communicate  with  the  space 
occupied  by  the  hernia. 

The  erythema  gradually  passed  down  the  legs,  succeeded,  as  it 
faded,  by  considerable  oedema,  with  some  tenderness  ;  the  arms  were 
affected  in  a  similar  way,  finishing  with  the  hands,  which  for  a 
time  were  very  much  swollen  and  tender,  and  apparently  caused  great 
pain  when  moved. 

For  some  days  there  was  little  change,  the  general  condition 
remaining  much  the  same ;  the  oedema  of  the  hands  and  feet 
gradually  disappeared,  the  hernia  remained  up,  and  the  ulcer  formed 
by  the  separation  of  the  slough,  though  discharging  a  good  deal, 
continued  to  gradually  improve,  although  the  temperature  still  re- 
mained above  100°. 

On  the  14th  inst.  she  had  an  attack  of  broncho-pneumonia,  but 
it  speedily  improved  under  appropriate  treatment,  and  the  patient 
is  now  progressing  favourably,  although  there  is  still  an  ulcer  of 
considerable  size  and  depth,  which,  however,  is  doing  well. 

The  swelling  of  the  labium  has  completely  disappeared,  having 
been  apparently  due  to  serous  infiltration. 


VI. -NOTES    OF    A    CASE    OF    TEANSPOSITION    OF    THE 
ABDOMINAL  AND  THORACIC  VISCERA. 

By  Harvey  Littlejohn,  M.A.,  M.B.,  B.Sc. 

E.  M.,  an  old  woman,  80  years  of  age,  was  found  dead  in  her 
house,  and  the  case  was  reported  to  the  authorities.  She  was 
small,  spare,  and  scarcely  looked  her  age.  Externally,  there  was 
no  sign  of  any  malformation  or  peculiarity  of  development. 

On  making  the  usual  mesial  incision  down  the  abdomen  the 
apparent  enlargement  and  prominence  of  the  left  lobe  of  the  liver 
attracted  attention ;  but  on  closer  inspection  this,  to  my  surprise, 
proved  to  be  the  right  lobe  occupying  the  left  hypochondrium. 
A  further  examination  showed  that  the  whole  of  the  thoracic  and 
abdominal  viscera  were  transposed. 


908        TRANSPOSITION  OF  ABDOMINAL  AND  THORACIC  VISCERA.   [APRIL 

The  heart  was  placed  obliquely  from  left  to  right,  the  apex  was 
directed  forwards  and  to  the  right,  and  was  situated  2  inches 
below  and  1  inch  to  the  inner  side  of  the  nipple.  The  ventricles 
and  auricles  were  transposed, — the  auricle  on  the  left  side  receiving 
the  superior  and  inferior  vena3  cavfe,  both  of  which  lay  to  the  left 
of  the  mesial  plane. 

The  aorta  arose  from  the  ventricles  on  the  right  side,  and,  run- 
ning upwards  and  to  the  left,  projected  1^  inches  beyond  the  left 
sternal  border  at  the  level  of  the  second  interspace,  whence  it 
curved  round  and  descended  on  the  right  side  of  the  dorsal  verte- 
brae. The  right  vagus  sent  a  recurrent  branch  under  the  arch, 
while  the  right  phrenic  crossed  the  arch  of  the  aorta.  The  inno- 
minate artery  ascended  the  neck  on  the  left  side,  the  subclavian 
and  common  carotid  arising  beyond  and  running  up  the  right 
side.  The  innominate  vein  from  the  right  side  passed  above  the 
aortic  arch  and  joined  the  superior  vena  cava. 

The  left  lung  was  the  largest,  and  possessed  three  lobes,  while 
that  on  the  right  side  had  only  two  and  a  well-marked  notch. 

The  liver  was  transposed  and  its  lobes  inverted,  the  left  being 
by  far  the  larger.  The  gall  bladder  was  situated  to  the  left  of 
the  middle  line. 

The  stomach  occupied  the  right  hypochondrium,  its  greater 
curvature  being  to  the  right,  and  the  cardiac  end  lying  immedi- 
ately under  the  diaphragm  on  that  side.  The  duodenum,  enclosing 
the  head  of  the  pancreas,  lay  to  the  left  of  the  mesial  plane.  The 
oesophagus  pierced  the  diaphragm  on  the  right  side.  The  spleen  lay 
in  the  right  hypochondriac  region,  the  anterior  border  being  notched 
and  the  posterior  rounded,  and  lying  in  relation  to  the  right  kidney. 
The  caecum  occupied  the  left  iliac  region,  while  in  the  same  region 
on  the  right  side  there  was  the  sigmoid  flexure.  The  rectum  ran 
over  the  right  sacro-iliac  joint  into  the  pelvis.  The  position  of 
the  abdominal  vessels  was  also  transposed, — the  aorta  lying  to  the 
right  side  of  the  vertebral  column,  the  vena  cava  to  the  left.  The 
usual  branches  were  given  off  by  both.  All  her  organs  were  in  a 
remarkably  healthy  condition,  and  death  was  apparently  due  to 
syncope,  the  result  of  old  age,  and  an  attack  of  bronchitis,  from 
which  she  was  suffering  at  the  time.  She  was  twice  married,  and 
bore  ten  children,  besides  having  at  least  three  miscarriages.  Only 
two  children  survive.  Neither  they  nor  their  children  have  any 
external  malformation,  nor  had  any  of  those  who  died,  so  far  as 
can  be  remembered.  The  deceased,  although  often  in  the  doctor's 
hands,  had  never  been  made  aware  of  her  interesting  anatomical 
peculiarity. 


1889.]  CASES   OF   SEUOUS   PLEURAL   EFFUSION.  909 

VIL— AN  ABSTRACT  OF  24  CASES  OF  SEROUS  PLEURAL 
EFFUSION  TREATED  BY  PNEUMATIC  ASPIRATION, 
WITH  REMARKS. 

By  J.  P.  Bramwell,  M.D.  and  L.R.C.S.  Ed. 

{Read  before  the  Perthshire  Medical  Association,  5th  March  1888.) 

Gkntlemkn, — The  time  is  not  very  long  past  since  pleuritic 
effusions  were  re/>arded  as  formidable  conditions,  wliich  it  was  con- 
sidered safest  to  remove  by  medical  appliances  alone.  The  routine 
practice  being — mercurials,  diuretics,  diaphoretics,  purgatives,  and 
blisters  often  repeated ;  the  strength  to  be  well  sustained  by 
nutritious  food  of  a  very  substantial  character.  To  this  was  added 
also  change  of  air  when  the  weather  was  suitable.  There  can  be 
no  doubt  that  excellent  results  were  obtained  in  this  way,  as 
s})ecially  shown  in  the  practice  of  the  late  lamented  and  gifted  Dr 
Hope  of  London.  Cases  of  this  kind,  however,  were  often  found 
intractable  and  disappointing,  and  the  patient's  health  was  not 
unfrequently  injured  by  confinement  and  prolonged  medication. 
Add  to  this  that  a  proportion  died  suddenly  and  quite  unexpectedly, 
and  of  those  who  recovered  not  a  few  did  so  with  an  adherent  and 
semifunctionless  lung.  Surgeons  in  former  times  fought  shy  of 
performing  paracentesis  thoracis,  as  fatal  results  from  the  large 
trocars  and  canulas  then  used  not  unfrequently  followed.  A  small 
canula  will  not  draw  it  off  without  an  aspirator.  All  this  is  now 
changed,  and  by  a  pretty  general  consensus  the  pneumatic  aspirator 
is  the  routine  practice.  Were  the  safety  of  the  operation  better 
known,  as  also  its  efficiency,  we  would  expect  the  usage  to  become 
universal.  Considerable  difference  of  opinion  exists  as  to  the  proper 
time  for  removing  such  effusions.  In  acute  cases,  where  there  is 
still  high  temperature  and  quick  pulse,  indicating  that  the  inflam- 
matory process  has  not  expended  itself,  it  is  considered  by  many 
unsafe  to  interfere,  even  although  the  effusion  is  considerable. 
Such  fears,  however,  are  not  well  founded  ;  the  fluid  can  be  removed 
with  perfect  safety,  and  with  the  effect  not  unfrequently  of  diminish- 
ing the  pyrexia.  By  such  means  pulmonary  compression  and 
adhesion  are  prevented,  and  the  function  of  the  lung  maintained. 
In  such  circumstances,  when  the  effusion  is  reproduced,  it  is  gener- 
ally in  small  quantities,  and  can  easily  be  removed  by  a  second 
aspiration.  When  the  pyrexia  has  disappeared,  and  the  case 
become  more  or  less  chronic,  nothing  can  be  gained  by  delaying  to 
aspirate.  Much  may  be  lost,  however,  and  there  can  be  nothing 
more  distressing  than  to  find  that  a  patient  who  was  destined  to  be 
aspirated  on  the  morrow  has  died  before  to-morrow  came.  Previous 
debates  which  we  have  had  on  the  subject  have  shown  that  this  is 
by  no  means  an  imaginary  picture.  "  So  when  we  are  in  doubt 
just  let  it  out."  It  is  a  well-known  fact  that  pleural  effusions  of 
moderate  quantity  may  remain  quiescent  for  lengthened  periods  of 


910  Dii  J.  p.  beamwell's  cases  of  [apkil 

time  witliout  causing  much  inconvenience ;  but  even  they  are  a 
standing  menace,  and  certainly  ought  to  be  removed  by  aspiration 
without  delay.  The  cases  which  I  shall  now  relate  are  only  given 
in  an  abstract  form,  as  my  object  is  not  to  present  a  few  cases  in 
detail,  as  I  have  already  done  on  a  previous  occasion,  but  to  group 
a  number  together,  in  order  to  aid  in  answeiing  some  debated  and 
important  questions. 

Case  I. — J.  Y.,  shoemaker,  aged  35 ;  healthy  man  ;  good  family 
history ;  suffering  from  an  acute  attack  of  pleurisy  from  cold ; 
effusion  on  right  side ;  aspirated  and  removed  40  oz.  of  pure  serum. 
There  was  no  return  of  the  fluid ;  function  of  lung  fairly  good. 
Fifteen  years  have  elapsed  since  then,  and  he  is  still  in  good 
health. 

Case  II. — J.  G.,  healthy  boy;  good  family  history  ;  aged  9  years. 
Acute  attack  of  pleurisy  on  right  side,  with  much  pain  and  pyrexia. 
At  the  end  of  a  week  an  effusion  had  formed,  and  although  the 
temperature  was  still  high,  I  aspirated  and  removed  35  oz.  of  pure 
serum.  In  a  week  after  a  smaller  effusion  having  formed,  I  again 
aspirated  and  removed  9  oz.  of  pure  serum.  Eecovery  perfect ; 
health  good  for  years  since. 

Case  III. — J.  M.,  a  boy,  aged  10  years ;  general  health  fairly 
good,  but  there  is  a  strumous  taint  in  the  family.  Began  to  feel 
out  of  sorts,  slightly  feverish,  short  in  breath,  with  a  troublesome 
dry  cough  now  and  again.  Stripped  and  examined  him.  There 
is  a  pleural  effusion  on  right  side.  Aspirated,  and  removed  35  oz. 
of  pure  serum.  There  was  no  reaccumulation,  and  the  cure  was 
complete ;  health  good  for  years  since. 

Case  IV. — R.  B.,  ploughman,  25  years  ;  has  always  enjoyed  good 
health  till  present  illness.  Has  had  an  acute  attack  of  pleurisy ; 
there  is  a  large  effusion  on  right  side.  Aspirated  and  removed 
70  oz.  of  fibro-serous  fluid.  Cure  complete  in  three  weeks ;  moving 
about  again. 

Case  V. — R.  B.,  traveller,  aged  30 ;  health  good  till  present 
illness;  an  attack  of  pleuro-pneumonia,  with  jaundice,  and  effusion 
on  left  side.  Aspirated  and  removed  30  oz.  of  serum.  Operation 
repeated  in  a  week,  and  another  10  oz.  removed ;  a  good  recovery. 

Case  VI. — W.  G.,  aged  30,  farmer's  son ;  health  good  till  two 
months  ago  ;  good  family  history.  Had  then  symptoms  of  pleurisy 
of  no  great  severity.  Has  at  present  an  effusion  on  left  side,  with 
cardiac  displacement,  from  which  he  suffers  little  inconvenience. 
Moves  about  in  open  air.  Aspirated  and  removed  27  oz.  of  pure 
serum.  Effusion  did  not  return ;  cure  perfect ;  health  good  for  years 
since. 

Case  VII. — M.  M'L.,  a  healthy  young  woman,  25  years,  and 
good  family  history,  a  seamstress.     After  exposure  to  cold  was 


1889.]  SEROUS   PLEURAL  EFFUSION.  911 

seized  with  a  severe  attack  of  left-sided  pleurisy.  There  was  high 
fever,  and  very  acute  pain  in  side,  and  in  about  eight  days  an 
effusion,  with  considerable  cardiac  displacement ;  respiration  much 
embarrassed.  Aspirated  and  removed  45  oz.  of  fibro-serous  fluid, 
which  did  not  return.  Much  relieved ;  good  recovery  ;  health  good 
for  years,  and  is  so  now. 

Case  VIII. — W.  G.,  aged  26,  an  apothecary's  assistant.  Has 
enjoyed  fair  health  up  to  present  time ;  family  history  somewhat 
exceptionable.  There  is  a  pleuritic  effusion  on  the  right  side, 
which  has  come  on  without  any  very  pronounced  symptoms  (latent). 
Very  little  respiratory  embarrassment.  Aspirated  and  removed  40 
ounces  of  pure  serum.  Effusion  did  not  return.  Sent  him  into  the 
country.     Recovery  good,  though  somewhat  tardy. 

Case  IX. — W.  R.,  railway  porter,  aged  27.  Health  good  before 
present  illness.  It  is  an  attack  of  pleurisy  from  exposure ;  effusion 
on  right  side.  Aspirated  and  removed  45  ounces  of  serum,  with 
much  relief  Effusion  did  not  return.  Recovery  good,  and  has 
remained  in  health  for  several  years. 

Case  X. — A.  C,  ast.  23,  medical  student.  Has  enjoyed  fair 
health  up  to  present  attack  of  pleurisy.  Ill  two  weeks.  Large 
accumulation  of  fluid  in  left  pleura,  with  displaced  heart.  Aspirated 
and  removed  70  ounces  of  serum.  Stood  operation  well.  Fluid 
reaccumulated ;  aspirated  again  two  weeks  after,  and  removed  90 
ounces  of  pure  serum.  After  this,  fluid  did  not  return.  He  did 
not  make,  however,  a  good  recovery.  Temperature  high ;  lost 
flesh ;  showed  signs  of  incipient  phthisis.  Went  to  Bournemouth 
for  the  winter,  and  was  there  attacked  with  symptoms  of  acute 
tubercular  meningitis,  of  which  he  died. 

Case  XI. — M.  W.,  aged  27  years,  seamstress.  Family  history 
not  quite  satisfactory  ;  never  been  robust.  Was  attacked  with 
symptoms  of  pleurisy  on  right  side,  and  there  is  an  effusion. 
Aspirated  and  removed  40  ounces  of  serum.  No  reaccumulation. 
Improved  considerably,  but  never  returned  to  perfect  health.  Two 
years  after,  symptoms  of  phthisis  developed  in  apex  of  right  lung ; 
the  disease  extended,  a  large  cavity  formed,  and  in  about  twelve 
months  from  the  commencement  of  the  disease  she  died  of  exhaus- 
tion. 

Case  XII. — J.  B.,  aged  30,  a  married  woman  with  young  family. 
Family  history  strumous  and  phthisical;  has  never  been  in  robust 
health ;  of  late  her  health  has  quite  failed,  and  she  is  very  breath- 
less. Was  admitted  into  the  Perth  Infirmary  under  my  care.  There 
is  a  very  large  effusion  on  right  side.  Aspirated  thrice  within  a 
week,  and  removed  109  ounces  of  pure  serum.  Breathing  much 
relieved,  but  general  condition  still  unsatisfactory ;  is  feverish  and 
comatosed.     A  hw  weeks  after  she  was  seized  with  pain  on  left 


912  Dii  J.  p.  bramwell's  cases  of  [apiul 

side,  and  also  over  abdomen,  and  sank  shortly  after.  Post-mortem 
examination  revealed  a  tubercular  peritonitis,  also  pleurisy  with 
recent  tubercles,  and  some  serous  effusion  on  the  left  side. 

Case  XIII. — A  female,  18  years.  There  is  phthisis  in  the 
family,  and  she  has  never  been  strong.  Was  attacked  with  symp- 
toms of  pleurisy,  and  an  effusion  having  formed  on  right  side,  I 
was  asked  by  her  medical  attendant  to  tap  iier.  This  I  did,  remov- 
ing 45  ounces  of  serum.  There  was  considerable  temporary  relief; 
but  a  second  effusion  formed,  which  was  removed  by  her  own 
medical  attendant,  and  found  to  be  pus.  We  incised  freely  and 
drained,  but  the  purulent  secretion  went  on,  and  our  patient  died  of 
suppurative  fever. 

Case  XIV. — J.  B.,  aged  26,  a  ploughman  ;  does  not  look  very 
robust;  caught  cold,  and  was  admitted  into  Perth  Infirmary  with 
symptoms  of  pleural  effusion  on  left  side.  Assisted  Dr  Frew 
(since  deceased)  to  aspirate,  and  removed  38  ounces  of  serous  fluid. 
Fluid  having  reformed,  it  was  removed,  and  found  to  be  purulent. 
His  chest  was  incised  freely,  drained,  and  washed  out  from  time  to 
time  with  disinfectants,  but  the  pus  still  continued  to  be  secreted. 
The  patient  succumbed  to  secondary  amyloid  degeneration  of  liver 
and  kidneys. 

Case  XV. — A  young  man,  aged  20 ;  admitted  into  Perth  In- 
firmary under  Dr  Frew  with  symptoms  of  pleurisy.  Effusion  of 
fluid  on  right  side.  Assisted  the  doctor  to  aspirate,  and  removed 
48  ounces  of  pure  serum.     Made  a  good  recovery. 

Cask  XVI. — A  healthy-looking  young  man,  22  years  ;  received 
into  Perth  Infirmary  under  Dr  Frew.  Pleurisy  on  right  side. 
There  are  signs  of  effusion.  Assisted  the  doctor  in  aspirating;  9 
ounces  of  serum  removed.     Eecovery  perfect. 

Case  XVII. — A  boy,  aged  10  years ;  private  patient  of  Dr 
Frew's.  Not  strong,  and  not  even  good  family  history.  Had  an 
attack  of  pleurisy  on  left  side,  with  effusion.  Assisted  the  doctor 
to  aspirate,  and  removed  30  ounces  of  pure  serum.  Recovered 
slowly.     Was  sent  into  the  country  ;  issue  uncertain. 

Case  XVIII. — W.  H.,  a  gamekeeper ;  powerful  young  man,  25 
years  of  age;  was  exposed  to  a  chill  after  a  deer  drive,  and  was 
attacked  with  pleurisy  on  left  side.  Acute  symptoms  gone  ;  walked 
about ;  came  to  my  house  at  Kingussie  for  advice.  Detected  a  large 
effusion  in  left  pleura,  and  heart  much  displaced  ;  pulse  very  irre- 
gular. Considering  him  in  imminent  danger,  I  telegraphed  for 
aspirator,  and  with  the  assistance  of  my  son  removed  70  ounces  of 
pure  serum,  very  rich  in  fibrin.  Effusion  did  not  return,  and  health 
kept  fairly  good,  but  the  function  of  left  lung  was  never  properly 
restored.  It  had  evidently  been  strongly  bound  down  by  fibrous 
bands  too  strong  to  lengthen  or  break.     His  left  side  underwent  a 


1889.]  SEllOUS   PLEUEAL   EFFUSION.  913 

process  of  contraction,  and  the   spine   became   slightly  curved,  an 
event  I  have  never  heard  of  before  in  cases  of  simple  serous  effusion. 

Case  XIX. — A  married  woman,  aged  25,  a  rheumatic  subject 
with  chronic  regurgitant  lesion  of  mitral,  was  seized  with  severe 
stitch  on  left  side  after  exposure  to  cold  ;  urine  loaded  with  lithates. 
It  was  an  attack  of  pleurisy  which  ended  in  effusion.  Aspirated, 
and  removed  43  ounces  of  serum  tinged  with  blood.  Repeated 
the  operation  two  weeks  after,  and  removed  a  second  effusion  of 
about  10  ounces.  Recovered  fairly  well.  Left  town  six  months  after- 
wards.    Was  since  informed  that  she  died  of  disease  of  the  heart. 

Case  XX. — R.  P.  R.,  aged  24,  town  postman,  is  by  no  means  a 
strong  mail.  Family  history  not  very  satisfactory.  After  a  wetting 
on  going  his  rounds,  was  seized  with  symptoms  of  croupous  pneu- 
monia on  right  side.  The  case  was  one  of  average  severity.  In 
about  a  week  from  the  commencement  of  his  pneumonia,  with  which 
pleurisy  also  must  have  been  combined,  I  detected  segophony  and 
aspirated.  The  effusion  was  serous,  and  only  amounted  to  about 
6  ounces.     He  made  a  good  recovery. 

Case  XXI. — Mrs  W.,  aged  50  years,  of  rather  feeble  constitution 
and  fairly  good  family  history,  was  seized  some  eight  months  ago 
with  pain  in  left  side  and  dry  cough  after  exposure  to  cold  winds 
along  seashore.  Tiiere  was  a  large  left-sided  effusion  with  cardiac 
displacement.  Aspirated,  and  removed  70  ounces  of  pure  serum. 
Great  relief  ensued,  but  there  followed  a  second  effusion  of  65 
ounces  of  serum,  which  I  also  aspirated.  Again  the  dyspnoea 
returned  after  a  time,  and  there  was  a  third  aspiration,  and  70 
ounces  again  removed.  A  formidable  group  of  symptoms  now 
began  to  appear,  e.g.,  contraction  of  left  pupil ;  diminution  in  pulse 
wave  in  the  left  radial  artery  ;  anasarca  of  left  side  of  face,  neck, 
mamma,  arm,  loin,  abdomen,  and  leg;  superficial  mammary  vein  much 
enlarged,  as  also  the  external  jugular.  The  whole  morbid  pheno- 
mena were  quite  unilateral.  My  patient  now  began  to  pass  into 
deeper  waters,  and  the  dyspnoea  so  distressing  that  I  again  aspir- 
ated, removing  60  ounces  of  chocolate-coloured  serum.  This  was 
again  repeated  two  weeks  after,  and  40  ounces  removed  of  a 
brighter  sanguineous  colour  than  before.  She  lived  about  a  week 
after,  and  died  at  last  of  pulmonary  cedema  of  the  right  lung,  which 
up  till  this  time  had  performed  its  function  well.  This  case  was 
certainly  a  very  peculiar  one,  the  causation  of  which  it  is  difficult 
absolutely  to  determine.  I  presume  at  first  it  was  a  simple  pleurisy, 
and  can  only  explain  the  latter  unilateral  phenomena  by  assuming 
that  the  thoracic  vessels  on  left  side  had  got  warped  by  the  effusion, 
and  bound  down  and  constricted  by  fibrous  exudation,  which 
became  organized  and  contracted.  Possibly  also  there  was  venous 
thrombosis. 

The  following  three  cases,  although  of  pleural  effusion,  are  not  of 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    X.  5z 


914  DU  J.   P.   BRAMWELL's   cases   of  [APRIL 

inflammatory  origin,  but  produced  by  organic  disease  of  tlie  heart. 
It  is  a  curious  fact  that  in  all  of  them  the  effusion  was  unilateral, 
which  certainly  could  not  have  been  anticipated,  considering  the 
cause  to  be  one  which  might  have  been  expected  to  have  acted  in 
both  sides  alike.  Some  authors  assert  that  it  must  be  always 
bilateral,  but  I  did  not  find  it  so.  We  should  not  forget  the  possi- 
bility of  this  occurrence  in  cardiac  affections,  but  should  watch  for 
effusions  of  this  kind,  and  remove  them  as  speedily  as  possible,  as 
their  presence  greatly  aggravates  the  patient's  sufferings  by  respira- 
tory embarrassment  and  increasing  the  danger  of  sudden  death. 

Case  I. — Went  70  miles  to  see  this  patient.  Found  him  suffer- 
ing from  advanced  cardiac  disease,  ascites,  and  anasarca  of  lower 
extremities ;  also  a  pleural  effusion  on  the  right  side.  He  is  30 
years  of  age,  and  has  been  for  years  in  a  tropical  country.  I 
emptied  his  abdomen  of  fluid  by  a  small  trocar  and  canula,  being 
the  only  instrument  I  had  with  me.  When  I  attempted  to  empty 
the  chest  by  the  same  instrument  only  a  little  serum  flowed  out. 
In  a  few  days  after  I  got  him  removed  to  the  Perth  Infirmary, 
where  I  aspirated  him,  and  removed  50  ounces  of  pure  serum  from 
the  right  pleural  cavity.  The  relief  which  followed  was  not  so 
great  as  I  had  anticipated,  owing,  I  presume,  to  the  cardiac  com- 
pensation being  completely  broken.  The  fluid  soon  reaccumulated, 
and  was  again  removed,  but  death  followed,  owing  to  the  advanced 
stage  of  his  cardiac  affection. 

Case  II. — A  female,  aged  60,  has  long  been  the  subject  of  cardiac 
disease  (mitral  stenosis.)  Of  late  her  breathing  has  been  much 
oppressed ;  indeed,  there  is  perfect  orthopncea.  The  cause  of  this, 
as  pointed  out  by  her  ordinary  medical  attendant,  was  a  right- 
sided  effusion.  We  aspirated,  and  removed  40  ounces  of  pure 
serum  with  great  relief  The  condition  of  the  patient  greatly 
improved  in  every  way  till  five  months  after,  when  sudden  death 
took  place  from  (probably)  pulmonary  thrombosis. 

Case  III. — Was  called  to  see  a  female,  aged  30  years,  who  had 
been  for  long  suffering  more  or  less  from  chronic  bronchitis  and 
dilated  heart.  To  make  matters  worse,  an  effusion  had  formed  in 
her  left  pleura.  I  aspirated  at  the  request  of  her  ordinary  medical 
attendant,  who  had  already  detected  the  effusion.  We  removed 
20  ounces  of  blood-stained  serum  with  not  much  relief.  The 
effusion  was  speedily  reproduced,  and,  although  removed  by  her 
medical  attendant,  she  only  survived  a  short  time  after. 

Although  these  cases  recorded  were  far  from  promising,  yet  it  is 
our  duty  to  remove  the  thoracic  effusion  ;  and  there  are,  undoubt- 
edly, cases  of  cardiac  disease  with  such  effusions  which,  when 
removed,  have  lived  for  considerable  periods  of  time  after.  Notably 
so  in  the  experience  of  Dr  Clifford  Albutt  of  Leeds,  who  has  con- 
tributed some  valuable  literature  on  the  subject  (vide  Practitioner). 


1889.]  SEROUS   PLEURAL   EFFUSION.  915 

I  sliall  eliminate  these  three  cases  of  cardiac  pleural  dropsy  from 
tlie  twenty  cases  of  inflammatory  pleural  effusion,  regarding  whicli  I 
shall  now  endeav^our  to  offer  a  few  remarks.  1st,  As  to  the  relation 
of  pulmonary  phthisis  to  such  effusions  either  as  a  predisponent  or 
as  a  resultant.  It  is  the  opinion  of  not  a  few  that  such  a  relation 
does  exist,  but  I  have  never  seen  this  authenticated  by  accredited 
facts,  nor  is  this  view  borne  out  by  the  cases  recorded.  Four  of 
them,  it  is  true,  showed  symptoms  afterwards  of  tuberculosis,  of 
which  they  died;  in  only  two  of  these,  however,  was  there  an 
liereditary  tendency  to  tuberculosis,  and  in  one  of  the  other  two 
fatal  cases  the  pulmonary  phthisis  did  not  appear  till  two  years 
after  the  effusion  had  been  removed,  so  that  it  could  not  in  fairness 
be  regarded  as  a  cause  of  the  phthisis.  We  must  bear  also  in 
mind  that  those  predisposed  to  pulmonary  phthisis  may  be  attacked 
by  pleurisy  with  effusion,  which  are  not  necessarily  connected  with 
phthisis,  just  as  they  are  attacked  by  many  more  diseases  which 
stand  in  no  such  relation.  No  doubt  those  who  suffer  from  dissem- 
inating pulmonary  tuberculosis  have  frequent  attacks  of  dry  pleurisy, 
but  this  is  apart  from  the  question  at  issue.  Regarding  this  Porits 
says,  "I  must  at  once  confess  my  belief — one,  indeed,  which  I  at 
first  somewhat  unwillingly  held — that  the  supervention  of  phthisis 
or  tuberculosis  during  a  primary  formed  pleuritic  effusion  is  very 
rare  ;  on  the  other  hand,  1  have  never  seen  phthisis  developed 
during  the  course  of  any  effusion."  Austin  Flint,  says  tiie  same 
author,  records  that  of  22  cases  of  pleurisy  preceding  phthisis 
(out  of  a  series  of  670  cases)  about  1  in  30  followed  imme- 
diately or  very  quickly ;  of  the  remainder,  in  2  only  was  the 
phthisis  less  than  a  year  in  developing;  and  in  the  majority 
of  them  more  than  two  years.  Of  53  cases  of  pleurisy  observed 
by  Dr  Blakeston,  not  one  became  phthisical  after  a  lapse  of 
several  years  after  recovery.  Dr  Frascr  of  the  London  Hospital 
considers  that  there  is  no  connexion  between  the  two.  Dr  Pye- 
Smith  (Guy's  Hospital)  says,  "  In  young  adults  pleurisy  often  ends 
in  consumption,  but  even  then  death  takes  place  not  from  the 
inflanmiation  or  effusion  or  adhesion  of  pleural  sac,  but  long  after 
from  diseases  of  the  lungs ;  and  in  these  cases  the  pleural  inflam- 
mation is  probably  not  tlie  occasion,  but  the  first  symptom  of  the 
grave  disease,  just  as  hseinoptysis  is  never,  I  believe,  the  cause  of 
tuberculosis,  though  sometimes  the  first  indication  of  its  presence." 

It  has  been  a  great  bugbear  to  many  that  the  tapping  of  serous 
effusions  of  the  thorax  are  apt  to  be  followed  by  a  reproduction  of 
a  purulent  character.  In  only  two  cases,  however,  of  those  recorded 
has  this  happened — one  being  of  bad  constitution,  with  a  consump- 
tive tendency.  Even  though  a  greater  danger  should  be  induced 
by  such  an  operation  in  very  exceptional  cases,  it  is  for  us  to  adjudi- 
cate for  the  good  of  the  many  and  not  of  the  few.  What,  we  ask, 
might  have  happened  if  all  had  remained  untapped  from  this  fear? 
What  even  to  the  two  exceptional  cases  to  which  we  have  referred? 


916  CASES   OF   SEROUS   PLEURAL   EFFUSION.  [APRIL 

Out  of  the  number  recorded  four  have  been  females  and  elgliteen 
males,  shovvini^  how  much  more  the  latter  are  predisposed  in  com- 
parison with  the  former,  from,  I  presume,  wets,  colds,  and  inclem- 
ency of  the  weather.  This,  I  think,  is  another  argument  against 
any  relation  between  inflammatory  ))leural  effusions  and  phthisis. 
An  outdoor  life  does  not  predispose  to  phthisis  as  does  an  indoor 
and  sedentary. 

It  is  a  well-known  fact  that  pleuritic  effusion  occurs  more  fre- 
quently on  the  left  side  than  the  right,  and  this  is  borne  out  by 
the  cases  recorded — the  effusion  being  twelve  times  on  the  left  side 
and  eight  on  the  right.  It  is  also  believed  by  not  a  few  that  right- 
sided  effusions  are  more  dangerous  than  lefr,1rom  the  more  frequent 
formation  of  venous  thrombi.  Trousseau  considers  that  nearly  all 
right-sided  cases  are  of  tubercular  origin,  but  that  opinion  has  long 
ago  been  refuted  by  Bowditch,  and  it  is  certainly  not  borne  out  by 
my  cases.  It  is  interesting,  however,  to  observe  that  two  at  least 
of  my  right-sided  cases  died  of  tuberculosis,  and  possibly  a  third  ; 
while  only  one  on  left  side  show  suspicious  symptoms  of  tubercle, 
and  died  afterwards  of  tubercular  meningitis. 

As  to  the  ages  of  the  patients,  three  were  below  20  years, 
seventeen  between  20  and  30,  and  one  between  30  and  40 ;  one 
was  50.  Tims  we  see  that  the  age  which  predisposes  most  to 
])leural  effusion  (probably  from  hard  toil  and  exposure)  is  from 
20  to  30 ;  above  these  are  only  two  cases.  Pleural  eftusions  in 
very  early  youth  are  generally  purulent,  and  associated  with  ex- 
anthematous  affections;  they  are  rarely  serous;  and  after  forty 
years  old,  be  the  cause  what  it  may,  there  is  not  the  same  liability 
to  pleuritic  effusions  of  an  inflammatory  character. 

Results  of  the  twenty-one  cases  recorded — five  died  ;  one  of  pul- 
monary phthisis  two  years  after  the  operation,  during  the  half  of 
which  there  were  no  pulmonary  symptoms;  one  of  tubercular 
meningitis  five  months  after  removal  of  fluid  from  chest ;  one  of 
tubercular  pleuritis  on  opposite  side  from  that  aspirated  and  tuber- 
cular peritonitis  one  month  after  aspiration  ;  two  of  suppurative 
fever,  one  of  these  having  also  amyloid  degener;ition.  One  died  of 
pulmonary  oedema  and  unilateral  dropsy  from  probably  strangula- 
tion of  bloodvessels  on  left  side,  induced  by  warping  and  cicatricial 
contractions  of  fibrous  bands  with  venous  thrombosis. 


VIII.— THE    OSTEOCLAST   AS   A   MEANS    OF    REDKESSIX'G 
DEFORMITIES  OF  LIMBS. 
By  Kenneth  M.  Douglas,  M.B. 

It  is  the  object  of  this  paper  to  draw  attention  to  a  method  of 
treatment  little  known  among  us,  but  strongly  upheld  and  success- 
fully carried  out  by  many  able  French  surgeons.  The  Society  de 
Chirurgie  in  1855  is  said  to  have  unanimously  rejected  osteotomy 


188t).]  ME   KENNETH   M.   DOUGLAS   ON   THE   OSTEOCLAST.  917 

in  the  treatment  of  genu  valgum  ;  and  although  that  unanimity 
certainly  does  not  now  prevail  in  France,  yet  the  osteoclast  in  a 
more  modern  and  ingenious  form  holds  its  own,  and  is  also  used  in 
]?elgium,  Italy,  and  elsewhere.  I  had  an  opportunity  in  the  clinique 
of  M.  MoUi^re,  in  Lyons,  of  seeing  the  procedure  carried  out  after  tiie 
most  recent  methods,  by  means  of  M.  Robin's  osteoclast. 

The  history  of  the  method  is  an  interesting  one.  In  1839  M. 
Louvrier  conceived  the  idea  that  the  deformity  present  in  many 
cases  of  osseous  ankylosis  of  joints  miglit  be  remedied  by  breaking 
the  bone  or  bones  in  the  neighbourhood.  The  idea  originated  in 
observation  of  the  results  of  such  fractures  accidentally  induced,  in 
attempts  to  remove  the  distortion  by  arthroclasis — the  older  method 
of  treatment.  The  adherents  of  modern  osteoclasis  themselves 
reprehend  Louvrier's  "  appareil  brutal,"  by  which,  in  truth,  the 
limb  was  made  straight,  and  other  injuries  inflicted,  the  nature  of 
which  the  surgeon  could  not  easily  predict.  Following  this 
example,  Langenbeck,  Billroth,  and  other  surgeons,  practised  for- 
cible straightening  of  the  distorted  limb,  either  by  the  hand  or  by 
some  elementary  piece  of  mechanism. 

In  1859  Demarquay  succeeded,  by  traction  on  the  limb,  in 
removing  the  deformity  due  to  malposition  of  an  ankylosed  knee; 
and,  the  patient  having  died  of  an  intercurrent  affection,  it  was 
found  that  the  result  of  the  traction  had  been  a  fracture  of  the  femur 
just  above  the  condyles.  At  this  period,  however,  no  precise 
method  existed  whereby  one  could  rely  on  obtaining  the  result 
aimed  at. 

Some  years  later  osteoclasis  received  fresh  impulse  from  the  efforts 
of  Delore,  in  whose  hands  manual  osteoclasis  in  genu  valgum 
apparently  gave  most  satisfactory  results.  The  proceeding  was  as 
follows: — The  patient,  suffering  from  knock  knee,  was  placed  near 
the  edge  of  the  bed  and  the  limb  rotated  outwards,  so  as  to  lie  on 
the  side.  A  cushion  was  placed  under  the  external  malleolus,  and 
the  knee  thus  rai.sed  above  the  plane  of  the  bed.  The  surgeon  then 
])ressed  down  on  the  inner  aspect  of  the  knee,  with  the  whole 
weight  of  his  body  on  the  hands.  When  he  was  fatigued  an 
assistant  took  his  place,  and  so  the  pressure  was  kept  up  for  a 
period  varying  from  five  to  thirty  minutes,  during  which  time  more 
or  less  noteworthy  cracking  sounds  were  heard.  The  deformity 
could  thus  be  completely  removed. 

M.  Tillaux,  who  was  the  first  in  Paris  to  employ  this  method 
of  the  Lyons'  surgeon  Delore,  modified  it  by  placing  the  inner 
surface  of  the  knee  downwards,  and  using  the  leg  as  a  lever  to 
remove  the  outward  curve  of  the  limb. 

So  much  force  was  often  required  in  carrying  out  this  method  of 
treatment,  that  in  1879  M.  Collin  introduced  a  most  elaborate 
piece  of  mechanism  for  the  use  of  surgeons  in  such  cases.  A 
description  of  this  instrument  would  be  at  once  needless  and  diffi- 
cult.    It  raised  high  expectation  among  the  believers  in  osteoclasy, 


918  Mil   KEN^'ETII   M.   DOUGLAS   ON   THE   OSTEOCLAST.         [aI'KIL 

and  doubtless  by  its  means  to  straighten  the  limb  was  made  easy ; 
but  to  know  what  was  done  in  procuring  that  desirable  result  was 
less  possible  than  in  the  manual  procedure  of  Uelore.  The  inventor 
would  seem  to  have  considered  the  muscles  of  the  surgeon  rather 
than  the  patient's  limb.  Whether  one  employed  the  method  of 
Delore  or  the  instrument  of  Collin,  the  principle  of  the  operation 
remained  tlie  same.  The  whole  force  employed  acted  directly  or 
indirectly  upon  the  knee-joint,  and  the  result  was  obtained  by  the 
wrenching  of  one  or  more  of  its  elements. 

What  exactly  happened  Tillaux  confesses  he  could  not  say. 
"Evidently,"  he  says,  "  we  produce  rupture  of  something"  {Qazette 
des  Hbpitaux,  1876),  but  as  to  what  that  is  he  merely  surmises. 

Delore  believed  that  he  produced  these  lesions  which  follow,  viz., 
separation  of  the  articular  surfaces,  as  evidenced  by  lateral  mobility 
of  the  joint;  tearing  away  of  periosteum  at  the  insertion  of  the 
external  lateral  ligament;  and  partial  separation  of  the  epiphysis 
of  the  lower  end  of  the  femur,  of  the  tuberosity  of  the  tibia,  and  of 
the  head  of  the  fibula. 

It  need  not  be  wondered  at  that  the  operation  was  followed  by 
pain,  swelling,  synovial  eflfusion,  and  an  arthritis  of  some  little 
intensity.  These  conditions  were,  as  a  rule,  but  temporary,  and 
were  relieved  by  absolute  fixation  of  the  part. 

In  a  case  of  Boeckel's  there  was  induced  an  attack  of  acute  sup- 
purative periostitis ;  and  although  Delore  states  that  in  250  cases 
he  met  with  an  almost  constant  success,  and  that  without  employ- 
ing any  undue  force,  yet  less  brilliant  results  frequently  followed 
the  procedure,  and  in  some  cases,  as  regards  deformity,  the  last  state 
of  the  patient  was  worse  than  the  first. 

Among  the  various  accidents  which  occasionally  followed  this 
treatment  of  genu  valgum,  were  separation  of  the  epiphysis,  per- 
sistent sub-acute  arthritis,  and,  most  common  of  all,  rupture  of 
the  external  lateral  ligament.  The  grave  objection  to  the  method 
was  that  the  surgeon's  action  was  in  a  large  measure  blind.  I'he 
limb  was  straightened  at  the  expense  of  anatomical  lesions  of  con- 
siderable moment,  and  the  functions  of  the  limb  were  often  seriously 
impaired. 

Collin's  apparatus  p|-oved  even  more  objectionable.  Experiments 
on  two  adolescent  cadavers  proved  that  the  periosteum  was  torn 
from  the  outer  aspect  of  the  femur,  and  the  condyles  were  fractured 
at  the  epiphyseal  line,  with  fissure  extending  to  the  spongy  bone. 
The  head  of  the  fibula  was  likewise  stripped  of  periosteum,  or  even 
itself  detached,  and  occasionally  the  semilunar  cartilages  were  dis- 
placed or  torn.  Similar  lesions  were  found  on  examination  of  a 
patient  who  died  accidentally  some  days  after  operation. 

In  children  Delore's  method  was  of  great  service,  as  one  may 
readily  believe  from  experience  of  manual  treatment  in  these  cases. 
In  no  case  did  Delore  believe  a  greater  force  than  100  kilogrammes 
(225  lbs.)  to  be  needful. 


188!).] 


MR  KENNETH  M.  DOUGLAS  ON  THE  OSTEOCLAST. 


919 


Sucli  were  the  former  methods  of  osteoclasy  ;  as  now  performed 
it  is  very  different,  and  I  believe  not  so  widely  known  among  us. 

Whilst  resident  in  tlie  Hotel  Dieu  of  Lyons  in  charge  of  the 
wards  of  M.  MoUi^re,  M.  Kobin  conceived  the  possibility  of  treating 
the  condition  of  genu  valgum  by  osteoclasy  on  an  entirely  new 
principle,  which  should  be  applicable  to  all  cases  and  devoid  of  risk. 
Recognising  that  the  fault  of  the  older  methods  lay  in  their  uncer- 
tainty, and  in  the  injury  done  to  the  knee,  he  set  to  work  to  devise 
a  method  which  should  put  no  strain  on  the  knee,  and  should 
liave  a  defined  and  known  action  upon  the  limb.  This  he  claims 
to  have  done  in  his  "  Osteoclasie  sus-condylienne,"  in  which  the 
femur  alone  is  acted  upon,  and  a  transverse  subperiosteal  fracture 
produced  at  any  point  selected  above  the  condyles. 

Robin's  apparatus  is  a  simple  but  most  effective  one,  by  which 
the  strongest  bone  may  be  broken  without  any  other  injury  being 
sustained  by  the  limb.  We  may  now  consider  it  as  applied  to  the 
treatment  of  genu  valgum,  though,  as  we  shall  afterwards  see, 
Robin  applies  it  to  many  other  deformities. 


The  osteoclast  consists  of  a  square  plate  or  table  {v.  Fig.,  A),  a 
steel  plate  (B)  shaped  so  as  to  lie  in  apj)Osition  to  the  extensor  aspect 
of  the  limb,  two  similarly  curved  steel  collars  (C),  a  leather  strap 
(D),  and  a  powerful  lever  (E).  As  may  be  seen  in  the  figure,  the 
thigh  rests  upon  the  square  table,  which  must  be  firmly  fixed  to 
the  operating  table  by  means  of  a  clamp  (H).  This  square  is  in- 
clined downwards  and  forwards,  so  that  when  the  patient  is  recum- 
bent it  supports  the  thigh  iji  all  its  length.  It  is  further  capable  of 
being  lengthened  or  shortened,  in  virtue  of  a  sliding  action  between 
two  superimposed  plates  of  which  it  is  composed.  It  must  be 
covered  when  used  by  a  sheet  of  leather  (G)  projecting  beyond  its 
upper  margin,  which  is  hollowed  out  to  receive  the  buttock.     The 


920  MU   KENNETH    M.   DOUGLAS   ON   THE   OSTEOCLAST.         [.VPUIL 

leather  must  also  project  beyond  the  lower  margin,  to  protect  the 
skin  from  injury  during  the  operation. 

The  steel  plate  (B)  is  likewise  covered  on  the  inner  surface  with 
leather,  and  embraces  the  thigh.  The  steel  collars  are  intended 
absolutely  to  fix  the  thigh,  which  they  do  by  being  applied  over 
the  ui)per  and  lower  borders  of  the  plate  (B),  and  being  screwed 
down  to  the  square  plate  on  which  the  thigh  rests  until  between 
plate  (A)  and  plate  (B)  the  limb  is  held  as  in  a  vice.  The  screws 
are  tightened  by  means  of  a  handle  (I),  which  is  so  constructed  that 
at  a  certain  point,  naturally  varying  in  each  case,  the  apparatus  can 
be  no  further  tightened,  and  the  operator  knows  that  the  limb  is 
fixed,  while  no  injurious  pressure  can  be  exerted.  The  leather  belt 
is  applied  outside  the  sheet  of  leather,  behind  the  condyles  of  the 
femur,  and  its  two  ends  are  fastened  as  short  as  may  be  to  hooks, 
one  on  either  side  of  the  lever.  This  lever  finds  a  fulcrum  on  the 
middle  of  the  lower  steel  collar  where  it  is  fixed. 

The  osteoclast  being  applied  and  the  thigh  grasped,  the  handle 
of  the  lever  is  carried  upwards  by  a  gradual  and  continuous  effort 
till  the  femur  yields,  with  or  without  an  audible  snap.  The  limb 
is  then  held  by  an  assistant,  and  the  whole  apparatus  at  once  dis- 
engaged by  turning  a  handle  (F).  The  bone  always  breaks  at 
the  lower  edge  of  the  anterior  plate  (B),  so  that  the  surgeon  can 
accurately  determine  where  the  fracture  shall  occur. 

M.  Molli^re,  holding  that  the  point  of  fracture  should  vary 
according  to  the  amount  of  deviation  from  the  normal  axis  ex- 
hibited by  the  limb,  gives  the  following  directions: — If  the  interval 
between  the  internal  malleoli  be  20  centimetres,  then  the  fracture 
should  be  made  at  the  bifui'cation  of  the  linea  aspera ;  if  the  interval 
be  40  or  50  centimetres,  then  the  bone  should  be  broken  2  or  3 
centimetres  nearer  the  joint,  so  that  the  angle  produced  may  be  less 
noticeable. 

MoUi^re  also  insists  that  the  foot,  after  the  apparatus  is  removed, 
should  not  only  be  brought  into  the  straight  line,  but  also  brought 
into  the  antero-posterior  axis  by  giving  it  a  proper  amount  of 
torsion. 

The  points  on  which  M.  Robin  mainly  insists  are  : — (1.)  That 
the  wliole  length  of  the  thigh  rest  on  the  posterior  plate,  in  order 
that  rotation  and  consequent  obliquity  of  the  fracture  may  be  pre- 
vented. (2.)  Absolute  fixation  of  the  thigh,  that  one  may  have 
certainty  as  to  the  point  of  the  fracture.  Robin  points  out  that  the 
soft  tissues  are  not  injured  in  virtue  of  the  spring  arrangement 
alluded  to  in  the  handle,  and  also  that  the  vessels  and  nerves,  being 
displaced  inwards,  are  not  greatly  compressed.  The  condyles  also 
protect  them.  (3.)  The  limb  must  be  held  extended  while  the 
screws  are  fastened  down,  to  prevent  any  dragging  upon  the  skin. 

One  can  say  with  truth  that  this  instrument  of  M.  Robin's  fulfils 
the  two  conditions  laid  down  by  him  in  its  conception.  The  knee- 
joint  is  beyond  its  sphere  of  action,  and  the  femur,  which  alone  is 


1889.]  MR   KENNETH   M.    DOUGLAS   ON   THE   OSTEOCLAST.  921 

injured,  is  fractured  subperiosteally  and  transversely ;  the  fracture 
may  be  complete  or  incomplete  at  the  will  of  the  operator,  so 
exactly  can  the  force  applied  be  estimated  and  controlled. 

Experiments  and  clinical  experience  alike  bear  out  these  state- 
ments ;  and  the  results  of  the  procedure  have,  according  to  its 
authors,  MM.  Molli^re  and  Robin,  being  always  favourable,  without 
any  accident  or  complication.  The  bone  is  never  splintered  nor 
fissured,  and  the  healing  is  without  any  appreciable  false  callus. 
The  effects  on  the  limb  contrast  markedly  with  those  produced  by 
Delore's  treatment ;  there  is  no  ecchymosis,  no  synovial  effusion,  no 
inflammatory  action  in  any  tissue. 

The  treatment  is  practicable  in  patients  of  all  ages,  though  not 
usually  needed  in  childhood ;  it  is  possible  in  dealing  with  bones  of 
all  degrees  of  density.  Usually  a  force  of  120  kilogrammes  is  suf- 
ficient (169  lbs.),  but  in  one  case  a  force  equal  to  1500  kilogrammes 
was  required,  and  no  untoward  consequences  followed. 

The  original  plan  of  Robin  was  to  redress  the  limb  at  once  and 
fix  it  in  plaster,  but  very  early  he  found  it  preferable  to  delay  the 
reduction  of  deformity  till  the  eighth  day  after  osteoclasis  had  been 
performed.  This  method  he  named  "  Redressement  tardif,"  and 
he  employed  it  in  nearly  all  cases.  On  the  eighth  day,  when  this 
second  stage  was  performed,  the  patients  were  usually  able  to  raise 
the  whole  limb  from  the  bed,  a  satisfactory  evidence  of  the  nature 
of  the  fracture  which  had  been  produced. 

The  many  reported  cases  of  genu  valgum  treated  by  Robin's  osteo- 
clasis reveal  most  satisfactory  results.  The  most  aggravated  degree 
of  deformity  is  amenable  to  treatment  by  this  method ;  the  patients 
are  usually  adolescents  and  young  adults,  but  in  men  of  23  and  32 
years  of  age  the  procedure  has  been  successfully  carried  out.  The 
"Redressement  tardif"  being  generally  adopted,  the  patients  were 
able  to  stand  and  walk  a  few  paces  one  month  after  operation, 
though  in  the  case  of  older  patients  fixation  was  maintained  during 
five  weeks ;  at  the  end  of  seven  or  ten  weeks  they  left  hospital. 
One  case  is  recorded  which  had  been  previously  subjected  to  treat- 
ment by  Delore's  method  without  success. 

In  two  most  successful  cases  recorded  by  M.  Robin,  consolidation 
after  osteoclasis  was  so  far  advanced  by  the  nineteenth  day,  that  the 
patients  were  allowed  to  stand  and  walk  ;  on  the  twenty-second  day 
one  of  these  was  exhibited  to  the  Society  of  Medical  Science 
at  Lyons,  so  thorough  was  the  strength  of  the  united  bone.  These 
patients  were  aged  16  and  17  years  respectively,  and  the  fracture 
was  in  the  one  case  1  centimetre  above  the  superior  margin  of  the 
patella,  in  the  other,  two  fingers'  breadth  above  the  same  point. 

In  the  majority  of  cases~Tio  sensible  callus  was  formed  ;  in  one 
only  did  a  slight  synovitis  supervene,  and  in  that  case  immediate 
straightening  of  the  limb  had  been  practised. 

As  to  the  time  for  interfering  in  these  cases,  Dr  Delarue  in  his 
thesis  (1884)  gives  M.  Robin's  views  as  follows: — In  adults  im- 

EDINBURGH   MED.    JOORN.,   VOL.   XXXIV. — NO.   X.  6  A 


922  MR   KENNETH   M.   DOUGLAS   ON   THE   OSTEOCLAST.         [APRIL 

mediate  interference  is  advisable ;  in  adolescents,  if  the  affection  be 
recent,  and  the  suspicion  exist  that  the  rachitic  process  is  still  in 
progress,  it  is  better  to  temporize ;  in  children  osteoclasis  is  not 
required,  but  splints  or  other  apparatus  should  be  applied. 

M.  Robin  also  strongly  advocates  the  use  of  osteoclasis  in  cases 
of  angular  ankylosis,  not  alone  when  after  chronic  disease  the 
bones  are  altered,  displaced,  and  ankylosed,  but  also  after  the 
subsidence  (for  some  months)  of  acute  arthritis  resulting  in  de- 
formity, or  after  white  swelling. 

Oilier  has  pointed  out  the  dangers  of  this  procedure  in  distortion 
from  chronic  osteo-arthritis,  whether  suppurative  or  not,  in  that 
by  it  the  inflammation  may  be  awaked  to  renewed  activity.  MM. 
Molli(5re  and  Robin  admit  that  the  treatment  is  contraindicated  in 
cases  where  the  disease  is  active,  where  cachexy  exists,  and  when 
the  condition  is  accompanied  by  osteitis  of  the  femur  and  the  pres- 
ence of  sequestra.  In  old  age,  also,  they  do  not  advocate  osteo- 
clasis. In  these  cases  of  angular  ankylosis  the  after-process  of 
consolidation  was  found  to  take  somewhat  longer  than  in  cases  of 
genu  valgum — from  fifty  to  fifty-six  days.  In  one  case  the  patient 
was  able  to  walk  on  the  thirtieth  day,  and  a  voluminous  callus 
had  formed. 

Among  twelve"  cases  reported  by  M.  Robin  no  complications  nor 
accidents  occurred ;  and,  according  to  his  experience,  the  line  of 
fracture  may  pass  through  an  old  abscess  cavity,  and  yet  no  relapse 
follow.  He  also  applies  the  osteoclast  when  the  disease  has  passed 
beyond  the  epiphyseal  line,  and  indicates  this  advantage  in  his 
method  over  arthrociasis — that  the  latter  is  only  possible  where  the 
ankylosis  is  of  limited  degree  and  fibrous,  with  no  history  of 
previous  suppuration  nor  alteration  of  the  articular  surfaces. 

When  the  deformity  is  so  extreme  that  the  knee  is  flexed  to  an 
acute  angle,  then  a  single  osteoclasis  is  insufficient,  and  M.  Robin 
therefore  breaks  the  bones  above  and  below  the  knee  on  separate 
occasions,  and  then  remedies  the  deformity.  By  this  and  other 
modifications  the  most  aggravated  cases  are  amenable  to  the  osteo- 
clast. 

The  exponents  of  osteoclasis  in  angular  ankylosis  would  lead  us 
to  the  following  conclusion  among  others  :  that  the  simplicity  of 
the  operation,  its  rapidity,  and  the  excellence  of  the  results,  should 
give  it  preference  to  all  other  methods,  resection  being  reserved  for 
those  rare  cases  of  ankylosis  in  which  the  persistence  of  the  patho- 
logical process  and  of  the  suppuration  in  the  bones  demands 
that  the  patient  be  speedily  relieved  from  this  source  of  general 
infection. 

M.  Molli^re  records  a  most  interesting  case  in  which  he  applied 
the  osteoclast.  It  was  one  of  most  aggravated  deformity,  in  conse- 
quence of  badly  united  fracture  of  the  tliigh  bone,  in  a  man  who,  after 
refusing  to  trust  his  femur  to  the  leading  osteotomists  of  Europe, 
finally  came  to  Lyons  and  submitted  to  osteoclasy.     The  result 


1889.]  MR   KENNETH   M.   DOUGLAS   ON   THE   OSTEOCLAST.  923 

seems  to  have  been  most  happy,  though  on  the  first  attempt  the 
strong  leather  strap  gave  way,  and  on  the  second  the  lever  bent ; 
yet,  finally,  a  fracture  was  induced  through  the  callus,  and  in  fifty 
days  the  man  was  well,  the  callus  being  much  diminished.  The 
force  employed  to  break  that  femur  was  one  of  1500  kilogrammes 
(3475  lbs.)  ;  since  that  occurrence  the  lever  has  been  made  of  tem- 
pered steel,  1  metre  long,  4  centimetres  in  diameter. 

A  most  interesting  application  of  osteoclasis  is  that  which  is 
made  in  the  treatment  of  malposition  after  CoUes'  fracture.  M. 
Bouilly  was  the  first  to  make  the  attempt,  in  1883,  with  bad 
result;  he  used  Collin's  instrument.  The  difficulty  in  these  cases 
lay  in  obtaining  a  point  of  application  for  the  strap,  i.e.,  a  point  for 
the  lever  to  act  upon. 

In  1884  M.  Robin  applied  his  osteoclast  to  such  a  case,  and  here, 
as  elsewhere,  a  most  successful  issue  is  recorded.  Since  then  the 
method  has  been  satisfactorily  employed  in  three  cases.  The  indi- 
cation for  his  interference  was  the  deformity  with  restricted  move- 
ments. The  forearm  was  clamped,  and  the  fracture  produced  through 
the  seat  of  the  old  injury;  consolidation  was  complete  fifteen  days 
after,  without  deformity  and  with  completely  restored  functions. 

I  also  saw  the  osteoclast  employed  to  reduce  old-standing  dis- 
locations backward,  both  of  the  knee  and  the  elbow,  the  proximal 
bone  being  fixed  and  the  distal  being  levered  into  position  by  the 
strap  placed  behind  their  superior  extremities. 

In  December  1888  M.  Robin  published  a  case  in  the  Bulletin 
Medical,  which  signalizes  a  further  advance  in  the  development  of 
his  method.  M.  Robin  recognised  that  while  in  breaking  the  bone 
a  considerable  amount  of  force  is  requisite,  in  the  straightening  of 
the  limb  the  surgeon's  action  must  be  gentle  and  gradual,  for  the 
reason  that  "  the  least  elastic  tissues  will  yield  if  their  degree  of 
elasticity  be  not  overpassed  in  the  surgeon's  endeavours,"  whereas 
too  sudden  and  severe  a  strain  on  these  tissues  induces  evil  results. 
He  therefore  introduced  the  plan  which  he  names  "  Redressement 
successif."  After  osteoclasy  the  member  must  be  left  for  some  days 
in  repose,  and  then  little  ly  little  brought  to  the  condition  of  health, 
the  movements  being  made  every  second  day  or  daily.  This  pro- 
ceeding he  has  not  found  to  interfere  with  the  process  of  consolidation. 

In  the  interesting  case  of  aggravated  deformity  of  the  knees 
(angular  ankylosis  and  spontaneous  posterior  luxation),  apropos  of 
which  this  newer  mode  of  treatment  was  devised,  the  process  of 
straightening  occupied  fifteen  days,  and  consolidation  was  complete 
on  the  fortieth  day.  The  result  at  the  time  of  record  (Dec.  1888), 
two  years  after  the  operation,  was  most  satisfactory.  The  knees 
were  not  treated  simultaneously. 

The  method  of  the  "redressement  successif"  is  briefly  as  fol- 
lows : — Before  any  treatment  is  adopted  a  plaster-of-Paris  splint  is 
moulded  to  the  limb,  and  with  this  is  incorporated  a  small  jointed 
metal  splint;   the  joint  must  lie   opposite  the  proposed  seat  of 


924  MR  KENNETH   M.    DOUGLAS   ON   THE   OSTEOCLAST.         [APRIL 

fracture,  and  the  plaster  splint  must  also  be  capable  of  having 
its  angle  altered  at  that  point.  On  each  occasion  after  the  osteo- 
clasis the  angle  of  the  splint  must  be  reduced  by  one  or  two 
degrees,  and  when  the  limb  lies  in  the  desired  position  it  is  fixed  in 
a  new  splint.  No  pain  should  ever  be  caused  during  the  straight- 
ening of  the  limb. 

M.  Robin  would  explain  the  fact  that  this  constant  moving  of  the 
broken  bone  does  not  retard  consolidation,  by  the  suggestion  that 
the  gap  between  the  ends  of  bone  being  gradually  increased  the 
callus  will  fill  it  more  readily  than  if  it  were  produced  all  at  once. 
This  idea  hardly  commends  itself  to  one;  probably  the  movement 
is  so  slight  and  so  regulated  by  the  splint,  which  prevents  any  gross 
displacement,  that  its  effects  would  be  inadequate  to  retard  union, 

M.  Robin  gives  the  following  as  indications  for  adopting  the 
"  redressement  successif  "  : — 

(1.)  Aggravated  cases  of  angular  ankylosis  of  the  knee. 

(2.)  Cases  where  from  undue  tension  arteries  or  nerves  seem  to 
be  endangered ;  these  risks  being  indicated  by  smallness  of  pulse 
and  pain  in  the  limb. 

(3.)  Cases  where  much  cicatricial  tissue  exists. 

Such  is  the  brief  survey  of  M.  Robin's  work  which  I  proposed 
to  make,  and  it  is  not  without  interest.  If  the  name  of  osteoclasis 
savours  somewhat  of  barbaric  surgery,  a  little  acquaintance  with 
the  method  itself  convinces  one  that  such  a  judgment  would  be 
unjust,  even  though  one  may  not  be  able  to  say  with  M.  MoUi^re, 
that  osteotomy  for  knock-knee  is  a  procedure  to  be  condemned,  and 
that  the  osteoclast  is  applicable  to  every  kind  of  deformity  in  the 
limbs. 

I  have  myself  been  fortunate  enough  to  witness  the  results  of 
osteoclasis  in  cases  of  knock-knee,  angular  deformity  of  the  knee, 
and  dislocation  of  the  knee  and  elbow.  The  latter  seemed  to  be 
rapidly  and  successfully  treated,  the  former  were  dealt  with  as 
accurately  and  satisfactorily  as  by  the  osteotomist's  chisel. 

To  enter  into  a  critical  comparison  of  the  two  methods  would  be 
beyond  my  purpose ;  but  perhaps  one  may  ask.  If  the  femur  can  be 
broken  as  M.  Robin  has  showed  us  it  can,  why  should  we  injure 
the  soft  parts,  however  trivial  the  risk  may  he  of  such  an  operation 
as  Mace  wen's? 

In  cuneiform  osteotomy  one  seems  to  have  certainly  a  preferable 
mode  of  redressing  extreme  deformity  of  the  bones,  though  MM. 
Molli^re  and  Robin  have  showed  that  there,  too,  in  their  hands  the 
osteoclast  will  do  the  work. 


1889.]  CLINICAL  REPOKT   OF   CASE   BY   DR   FINLAY.  925 

CLINICAL  REPORT  OF  CASE  AT  LEITH  HOSPITAL 
Under  the  Care  of  Dr  Finlay.     Notes  of  Case  by  F.  A.  Juckes,  M.B. 

Wound  of  Abdomen  and  Small  Intestine. 

C.  D.,  set.  24,  a  Danish  sailor,  admitted  to  Leith  Hospital  at 
10.45  P.M.  on  25th  June  1888.  Shortly  before  admission  he  quar- 
relled with  an  Italian  sailor  in  a  dancing-hall,  and  during  the 
dispute  was  stabbed  in  the  abdomen  with  a  dagger.  He  was  at 
once  brought  up  to  Hospital. 

On  examination,  an  incision  was  seen  through  his  trousers,  shirt, 
and  vest.  Patient  was  sitting  up  in  a  chair  when  seen.  On  re- 
moving his  clothes,  several  coils  of  small  intestine  distended  with 
flatus  were  seen  protruding  from  the  abdomen  on  the  left  side 
about  3  inches  from  the  umbilicus.  He  was  very  drunk ;  other- 
wise he  seemed  in  a  fairly  good  condition.  Pulse  full,  regular,  rather 
fast.  The  wound  in  the  abdominal  wall  appeared  to  be  about 
1^  inch  long,  and  the  intestine  was  found  to  be  wounded  in  two 
places — one  incision  being  longitudinal,  the  other  transverse.  Each 
cut  was  rather  more  than  an  inch  in  length. 

The  patient  was  chloroformed,  and  the  intestines  carefully  washed 
with  warm  boracic  lotion  ;  the  wounds  in  the  intestine  were  then 
sewn  up  with  a  continuous  suture  of  carbolized  catgut ;  the  stitches 
were  not  passed  through  the  whole  thickness  of  the  intestinal  wall, 
and  the  edges  were  inverted.  The  parietal  wound  having  been 
enlarged,  the  intestines  were  returned,  and  the  abdomen  closed  up. 
The  incision  through  the  fascia  and  muscles  was  first  closed  with 
catgut,  and  then  the  skin  united  with  silver  wire  and  horse-hair; 
dressed  with  corrosive  wool. 

June  26. — Doing  well.  No  pain  in  the  abdomen.  Half  a  grain 
of  morphia  was  given  hypodermically,  and  two  1-grain  opium  pills 
during  the  night.  Ordered  pil.  opii,  gr.  1,  as  often  as  necessary  to 
keep  him  drowsy,  and  a  teaspoonful  of  Carnrick's  beef  peptonoids 
in  four  ounces  of  gruel  as  an  enema  every  six  hours.  Allowed  to 
suck  a  little  ice.     He  frequently  vomits  clear  coffee-coloured  fluid. 

J^ine  27. — In  the  morning  still  vomiting  the  same  looking  fluid 
and  bile.  Slight  abdominal  distension,  but  no  pain.  The  enemas 
had  to  be  stopped,  as  they  caused  much  discomfort.  A  lithotomy 
tube  was  inserted  into  the  rectum,  and  tied  in  to  facilitate  the 
escape  of  flatus ;  this  gave  great  relief.  Ordered  beef  peptonoids 
as  suppositories. 

June  28. — Looks  well ;  no  pain  ;  slightly  jaundiced.  The  opium 
is  still  being  continued.     Wound  dressed,  and  apparently  healed. 

July  3. — Food  given  by  the  mouth  for  the  first  time ;  allowed 
very  small  quantities  of  peptonized  beef-tea  every  four  hours. 

July  14. — Up  out  of  bed  for  the  first  time.  Food  gradually  in- 
creased in  quantity.     On  July  21st  he  got  ordinary  diet. 

July  25. — Discharged  quite  well. 


926  CLINICAL   REPORT   OF   CASE   BY  DR   FINLAY.  [APRIL 

His  temperature  was  never  above  normal  throughout. 

It  was  afterwards  found  tliat  on  July  7tli  he  ate  some  ship's 
biscuits  which  another  patient  gave  him,  but  with  apparently  no 
bad  effects. 

Remarks  hj  Dr  Finlay. — The  chief  point  of  importance  in  this 
case  is  the  fact  that,  notwithstanding  the  presence  of  two  wounds 
in  the  intestine,  each  of  more  than  1  inch  in  length,  it  was  distended 
with  flatus,  the  escape  of  which  was  effectually  prevented  by  the 
eversion  and  overlapping  of  the  mucous  coat  which  had  taken  place 
at  both  wounds.  So  much  was  this  the  case  that  at  first  sight  it 
was  impossible  to  suppose  that  wounds  of  such  size  existed.  This 
point  is  of  practical  importance,  since  the  absence  of  the  escape  of 
flatus  or  fluid  contents  might  be  relied  on  as  proof  also  of  the 
absence  of  a  wound,  and  might  thus  lead  to  the  hasty  return  of  the 
protruded  coils  of  intestine. 

In  Erichsen's  Surgery  it  is  stated  with  reference  to  this  subject: 
— "  If  it  be  a  mere  puncture,  or  even  an  incision  of  two  or  three 
lines  in  length,  eversion  or  prolapsus  will  take  place,  so  as  to  close 
it  sufficiently  to  prevent  the  escape  of  the  contents.  If  the  aperture 
be  above  four  lines  in  length,  this  plugging  of  it  by  everted  mucous 
membrane  cannot  occur,  and  then  the  contents  of  the  bowel  escape ; 
but  even  in  these  circumstances  there  will  be  a  tendency  to  pro- 
trusion of  the  membrane,  which  forms  a  kind  of  lip  over  the  edge 
of  the  cut." 

It  appears,  however,  that  eversion  may  prevent  escape  of  the 
contents  of  the  bowel  in  cases  of  wounds  of  a  much  larger  size  than 
that  mentioned  by  Mr  Erichsen,  for  it  was  only  after  considerable 
handling  of  the  coils  during  examination  that  any  escape  of  their 
contents  took  place  in  the  case  under  consideration. 

As  to  the  stitching  of  the  wounds  in  the  gut,  the  important  points 
seem  to  be — 

1.  To  invert  the  edges  of  the  wound  so  as  to  oppose  one  serous 
surface  to  the  other. 

2.  To  insert  the  stitches  with  scrupulous  care,  so  as  to  retain  the 
surfaces  in  accurate  contact. 

3.  To  pass  the  stitches  through  so  much  of  the  intestinal  wall  as 
will  give  them  a  firm  grip,  but  not  to  pass  them  into  the  lumen  of 
the  bowel. 

Another  point  of  interest  in  the  case  is  that,  in  returning  the  pro- 
truded coils  of  intestine,  great  care  had  to  be  exercised,  in  order  to 
avoid  excessive  distension  of  the  gut.  To  this  end  the  parietal 
wound  was  enlarged,  and  the  flatus  was,  as  far  as  possible,  pressed 
from  the  protruded  portion  of  the  bowel  before  returning  it.  Tliis 
point  is  worthy  of  note,  because  if  such  precautions  were  neglected  it 
is  quite  possible  that  the  distension  might  cause  so  great  a  strain 
on  the  stitches  as  to  burst  them. 

I  was  much  struck  with  the  same  tendencv  to  excessive  distension 


1889.]  CLINICAL   REPORT   OF   CASE   BY   DR   FINLAY.  927 

recently  when  operating  on  a  large  umbilical  hernia,  when  the  dis- 
tension considerably  retarded  the  return  of  the  gut.  Of  course, 
where  a  recently  stitched  wound  of  the  protruded  gut  is  present, 
such  distension  might  be  productive  of  disaster. 

In  the  after-treatment  one  remarkable  fact  was  the  immediate 
relief  from  suffering  caused  by  flatulence  in  the  lower  bowel  effected 
by  the  introduction  of  a  tube  into  the  rectum. 


|3avt  ^cconti. 


EEVIEWS. 

The  Physician  as  Naturalist:  Addresses  and  Memoirs  hearing  on 
the  History  and  Progress  of  Medicine  chiefly  during  the  last 
Hundred  Years.  By  W.  T.  Gairdner,  M.D.,  LL.D.,  Professor 
of  Medicine  in  the  University  of  Glasgow ;  President  of  the 
British  Medical  Association;  Physician  in  Ordinary  to  H.M.  the 
Queen  in  Scotland.     Glasgow  :  James  Maclehose  &  Sons. 

The  twelve  lectures  which  form  this  neat  volume  all  bear  directly 
or  indirectly  on  the  progress  of  the  profession — in  learning,  in  status, 
and  in  power  of  healing  in  the  best  sense  of  the  word. 

They  are  not  arranged  in  chronological  or  any  order,  for  the 
last  in  point  of  time  is  the  first  in  the  book,  to  which  it  gives  the 
name.  That  remarkable  address,  delivered  to  the  British  Medical 
Association  in  Glasgow  in  August  1888,  will  be  fresh  in  the 
memories  of  most  of  our  readers.  Striking  a  high  key-note  in  the 
noble  definition  of  a  Physician  as  a  Naturalist  in  the  fullest  and 
best  sense  of  the  word,  it  keeps  up  the  same  elevated  tone  in  dis- 
cussing the  training  of  the  profession  and  the  E-eligio  Medici.  To 
it  he  has  now  added  a  valuable  and  interesting  appendix  in  the 
form  of  an  extract  from  an  introductory  address,  in  which  he 
describes  the  character  and  education  for  a  Scotch  medical  student. 

Cliapter  II.  is  a  sort  of  Apologia,  not  for  his  own  life,  but  for  the 
profession,  on  the  text,  Has  the  art  of  Medicine  advanced  within 
the  last  hundred  years?  The  answer  is.  Yes,  and  the  points  are 
stated  with  much  fairness  and  care.  The  next  chapters  are  admir- 
ably practical,  on  the  treatment  of  fever  and  the  use  of  alcohol.  To 
the  four  chapters  we  might  put  as  a  motto,  "  Lacte  non  vino," 
Every  one  who  knows  Professor  Gairdner's  care  in  observation, 
his  absolute  accuracy  of  statement,  and  his  single-eyed  devotion  to 
getting  at  the  truth,  will  value  these  contributions  to  practical 
medicine. 

Tiien  follows  a  lecture  on  Mind  and  Body,  delivered  to 
the  Medico-Psychological  Association ;  and  another  on  Sanitary 
Science,  delivered  in  Section  I.  of  the  Sanitary  Institute  in  Glasgow 
in  1885;  one  on  the  Progress  of  Pathological  Science,  delivered  as 


928  THE  PHYSICIAN  AS  NATURALIST,  ETC.  [aPRIL 

President  to  the  Pathological  and  Clinical  Society  of  Glasgow. 
Non  cuivis  contigit  adire  Corinthum.  To  few  men  in  this  age  of 
specialism  is  it  given  to  have  a  word  to  say  to  such  diverse 
audiences ;  and  yet  no  one  can  say  of  Professor  Gairdner  that  he 
has  sought  such  honours,  or  has  failed  to  do  his  duty  when  such 
posts  have  been  thrust  upon  him.  He  is  a  many-sided,  much- 
labouring,  much-enduring  man.  Like  his  great  prototype,  he  has 
stopped  his  ears  to  the  syren  song  of  the  vox  populi,  has  escaped 
Circe  and  her  idle  and  full-fed  throng,  and  has  worked  steadily  at 
his  profession,  and  made  himself  a  true  physician.  We  in  Edin- 
burgh who  worked  with  him  thirty  years  ago  know  how  his  wards, 
the  pathological  theatre,  and  the  lecture-room  filled  all  his  day ; 
liow  he  would  teach  so  long  as  the  light  lasted  in  the  dark  wards 
in  the  short  winter  days,  hurry  off  to  Surgeons'  Hall  for  his  lecture, 
and  back  again  after  four,  if  he  had  not  worked  up  his  case.  The 
arduous  labours  and  endless  calls  on  time  of  a  great  consulting 
physician  may  give  him  now  less  time  for  purely  original  work,  but 
the  same  devotion  to  scientific  medicine  and  professional  progress 
still  remain  his  chief  aims. 

The  next  essay  on  Homoeopathy,  written  more  than  twenty  years 
ago,  has  a  historical  interest.  This  generation  can  hardly  understand 
the  excitement  in  the  debating  societies  and  journals  caused  by  the 
discussion  of  the  tenets  of  this  now  nearly  exploded  delusion.  It 
was  actually  considered  worthy  of  serious  argument.  This  essay 
is  a  crushing  exposure  of  the  fallacies  in  theory  and  delusions  in 
the  practice  of  its  then  honest  and  simple-minded  votaries.  The 
so-called  homoeopathy  of  the  present  age  is  not  that  of  Hahnemann, 
but  rather  a  shrewd  use  of  modern  pathology  and  rational  medicine 
by  men  who  write  their  names  in  the  Homceopathic  Directory,  keep 
their  globules  and  dilutions  for  the  old  women  of  both  sexes  who 
suffer  only  from  idleness  or  fancy,  but  are  found  to  treat  cases  of 
real  illness  on  very  much  the  same  principles  as  their  less  plausible 
neighbours. 

The  last  chapter  contains  a  most  interesting  sketch  of  the  life  of 
that  great  and  good  man,  William  Pulteney  Alison.  This  appeared 
in  the  columns  of  this  Journal  nearly  thirty  years  ago,  and  will  be 
read  with  pleasure  by  those  of  this  generation  who  only  knew  Dr 
Alison  by  his  writings. 

We  think  Dr  Gairdner  has  done  wisely  to  republish  those 
interesting  lectures  and  addresses. 


De  la  Dermatite  Herpetiforme  de  Duhring;  Arthritides  huUeuses  de 
Bazin  ;  Pemphigus  pruriginosus  de  M.  le  professeur  Hardy ; 
Hydroa  de  quelques  auteurs  anglais.  Par  le  Dr  Bkocq,  Medecin 
des  hdpitaux.     Paris  :  G.  Masson :  1888. 

It  was  so  recently  as  1884  that  Dr  Duhring  of  Philadelphia  first 
drew  attention  to  a  peculiar  disease,  characterized  perhaps  most 


1880.]  DE    LA.   DEEMATITE    HERPETIFOEME   DE   DUHRING.  929 

remarkably  by  the  protean  type  of  its  lesions,  to  which  he  attached 
the  name  of  dermatitis  herpetiformis.  He  has  since  then  frequently 
directed  attention  to  the  ailment  in  a  series  of  contributions  to 
various  journals,  and  the  subject  has  attracted  very  great  interest. 
As  is  usual,  however,  those  wlio  have  written  on  the  question  have 
not  in  all  cases  been  satisfied  with  the  term  assigned  to  the  com- 
plaint by  Duhring,  and  confusion  has  arisen  in  consequence.  In 
the  work  before  us  Dr  Brocq,  one  of  the  most  intelligent,  and  we 
may  add  one  of  the  most  philosophical  of  the  younger  French 
dermatologists,  has  collated  all  that  has  been  published,  has 
arranged  and  classified  this,  has  augmented  the  material  by  many 
cases  previously  unrecorded,  and  has  made  deductions  which  vastly 
simplify  the  whole  matter,  while  he  has  at  the  same  time  brought 
out  more  fully  some  analogies  only  very  imperfectly  understood 
hitherto.  Thus  Duhring  was  inclined  to  include  in  the  disease  as 
formulated  by  him  that  known  as  impetigo  herpetiformis,  originally 
described  by  Hebra  and  Kaposi  ;  this  Brocq  shows  is  entirely 
distinct.  Again,  the  complaint  called  herpes  gestationis  has  been 
confounded  with  impetigo  herpetiformis.  Brocq  proves  that  this 
has  the  closest  relations  to  dermatitis  herpetiformis,  if  not  actually 
a  variety,  but  is  quite  sharply  differentiated  from  impetigo  herpeti- 
formis. In  much  the  same  way  he  has  pointed  out  the  connexion 
which  exists  between  the  dermatitis  of  Duhring  and  some  forms  of 
pemphigus,  of  herpes,  and  of  hydroa,  as  these  are  looked  at  by 
different  authors.  The  features  which  characterize  dermatitis  her- 
petiformis may  be  stated  shortly  as  follows : — 1.  The  eruptive 
phenomena  are  polymorphicor  multiform, andconsist of — (a.)  Primary 
lesions,  erythematous  patches  more  or  less  distinctly  defined,  papules, 
vesicles,  vesico-papules,  blebs,  pustules,  vesico-pustules,  dissemin- 
ated or  variously  grouped;  (6.)  Secondary  lesions,  excoriations,  crusts, 
brownish  macules.  2.  The  itching  is  very  intense.  3.  The  disease 
is  one  of  very  long  duration,  and  progresses  by  successive  outbreaks, 
which  may  present  appearances  as  various  as  the  eruptions  them- 
selves. 4.  Those  attacked,  though  possibly  a  little  weakened,  pre- 
serve, as  a  rule,  a  good  condition  of  general  health.  Men  seem  to 
be  more  frequently  affected  than  women,  and  some  degree  of  indi- 
viduality is  impressed  on  the  complaint,  since  eruptions  primarily 
pustular  are  apparently  more  common  in  America  than  in  France. 
It  is  apparently  always  aggravated  by  the  administration  of  iodide 
of  potassium.  Dr  Brocq  very  carefully  formulates  the  diagnostic 
points  which  separate  it  from  erythema  multiforme,  from  acute  and 
chronic  pemphigus,  and  from  urticaria  bullosa.  In  particular,  he 
describes  a  case  in  which  a  man  who  had  been  treated  for  a  con- 
siderable period  with  salicylate  of  soda  for  rheumatism  developed 
an  eruption  of  wheals  and  of  bullae,  the  latter  both  primary  and  on 
the  wheals,  and  accompanied  with  pruritus.  When  iodide  of 
potassium  was  given  the  rash  disappeared.  Herpes  gestationis 
starts  on  the  extremities,  especially  on  the  arms,  the  itching  is 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.   X.  6  B 


930  DE  LA.  DKKMATITE  HERPETIFORME  DE  DUHRING,  ETC.       [APRIL 

violent,  tlie  eruption  is  multiform,  though  the  blebs  seldom  become 
purulent,  the  general  health  remains  good,  and  it  always  ends 
favourably.  Impetigo  herpetiformis  originates  near  the  groin,  the 
umbilicus,  the  breast,  or  margin  of  the  axilla;  it  is  characterized 
from  the  outset  by  superficial  miliary  pustules,  grouped  in  a  circle 
round  a  central  crust ;  the  eruption  maintains  this  sole  and  unique 
arrangement  while  it  lasts,  the  fever  is  intense,  the  general  condition 
is  very  grave,  and  death  is  the  rule.  Dr  Brocq  has  not  been  able  to 
resist  the  temptation  to  suggest  a  fresh  and,  in  his  opinion,  a  more 
suitable  appellation.  He  names  dermatitis  herpetiformis,  prurigin- 
ous  polymorphic  dermatitis  with  successive  outbursts  ;  of  this  again 
he  describes  an  acute  variety  ;  herpes  gestationis  he  calls  recurrent 
pruriginous  polymorphic  dermatitis  of  pregnancy  ;  impetigo  herpe- 
tiformis he  leaves  unaltered.  The  work  is  a  most  valuable  one,  as 
bringing  together  in  an  easily  accessible  form  a  mass  of  information 
previously  scattered,  and  cannot  fail  to  add  materially  to  the  reputa- 
tion of  its  author. 


Annales  de  Dermatologie  et  de  Syphiligraphie.  Publi^e  par  MM. 
Ernest  Besnter,  A.  Doyon,  A.  Fuurnier,  P.  Horteloup,  and 
P.  Merklen.  Deuxifeme  S^rie,  Tome  IX.  Paris  :  G.  Masson  : 
1888. 

Journal  of  Cutaneous  and  Genifo- Urinary  Diseases.  Edited  by 
Prince  A.  Morrow,  A.M.,  M.D.  Volume  VI.  New  York: 
William  Wood  &  Co. :  1888. 

These  journals,  representative  of  the  progress  of  dermatology 
and  venereal  diseases  in  France  and  in  America  respectively,  fully 
maintain  the  reputation  they  have  earned  in  former  years.  If  in 
the  French  periodical  there  is  a  little  more  of  the  speculative 
element  visible,  while  in  the  American  the  practical  rather  pre- 
dominates, national  idiosyncracies  may  perhaps  in  some  measure 
account  for  this.  The  volume  of  the  Annales  for  1888  is  specially 
remarkable  for  an  able  paper,  extending  through  several  numbers, 
by  Dr  Brocq,  which  is  noticed  more  fully  elsewhere  ;  but  in  addition 
to  an  unusual  proportion  of  short  articles  of  interest,  there  is  an 
important  contribution  by  H.  Leloir  on  the  organization  and  teaching 
of  syphilis  and  dermatology  in  the  Universities  of  Germany  and 
Austro-Hungary.  In  the  American  journal,  among  other  contribu- 
tions which  are  of  value  is  one  by  Klotz  on  lupus  erythematosus 
of  the  hand  and  foot,  and  another  by  Heitzmann  on  microscopical 
studies  of  melanotic  tumours  of  the  skin,  while  the  editor  relates 
a  remarkable  case  of  tuberculosis  papillomatosa  cutis.  Not  least 
interesting  are  the  reports  of  the  Dermatological  and  Genito- 
Urinary  Societies,  the  latter  a  new  departure,  and  of  the  American 
Dermatological  Association,  the  vigorous  condition  of  which  proves 
the  zest  with  which  all  questions,  whether  cutaneous  or  venereal, 
are  investigated  by  our  transatlantic  friends. 


1889.]  DISEASES   OF   THE   NERVOUS   SYSTEM,   ETC.  931 

Clinical  Lectures  and  Essays  on  Diseases  of  the  Nervous  System. 
By  John  Syer  Bristowe,  M.D,  Lond.  London :  Smith,  Elder, 
&  Co. :  1888. 

Under  the  above  title  Dr  Bristowe  has  given  us  a  most  interest- 
ing and  instructive  series  of  cases.  These,  as  he  is  careful  to  men- 
tion in  his  preface,  "have  no  supplemental  connexion  wiih  his 
larger  work,  but  have  simply  been  made  the  basis  of  clinical  and 
other  lectures  which  have  been  delivered  from  time  to  time,  or  of 
essays  or  papers  which  have  been  published  or  prepared  for  publi- 
cation." As  a  matter  of  fact,  several  of  them  liave  ah-eady  appeared 
in  the  Practitioner,  Brain,  Medical  Times  and  Gazette,  and  Lancet, 
or  in  the  Transactions  of  the  Clinical  or  Ophthalniological  Society, 
or  in  St  Thomas  s  LLospital  Reports.  All  of  them  are  extremely 
pleasant  reading,  alike  from  the  lucidity  of  the  style  and  the  interest 
of  the  matter.  They  are  well  worthy  of  perusal  and  of  attentive 
consideration  by  every  clinician. 


Malaria;  and  the  Causation  of  Periodic  Fever.  By  Henry  B. 
Baker,  M.D.  The  Journal  of  the  American  Medical  Association, 
November  10,  1888,  page  651.     With  12  Charts. 

Dr  Baker's  paper  is  of  considerable  interest.  It  is  ingenious, 
and  shows  evidence  of  painstaking  research.  It  is  written  to  prove 
that  malaria  is  the  result  of  chill,  and  it  is  for  this  reason  we  call 
attention  to  it,  as  we  had  thought  that  now-a-days  no  one  could  be 
found  who  would  be  daring  enough  to  stand  forward  as  an  advocate 
for  what  we  consider  to  be  a  lost  cause.  Since  1871,  when  Dr  Oldham 
published  his  book  What  is  Malaria  ?  we  do  not  remember  having 
seen  any  serious  attempts  to  uphold  the  chill  theory  of  the  produc- 
tion of  malaria,  although,  of  course,  it  must  be  admitted  that  a  chill 
will  induce  a  paroxysm  of  ague.  This  notwithstanding,  we  agree 
with  Dr  Lee,  who  said,  in  the  discussion  on  this  paper,  "  I  think 
Dr  Baker's  paper  the  strongest  and  most  ingenious  argument  in 
favour  of  a  theory  which  has  always  seemed  to  me  weak  and  in- 
conclusive, that  I  have  ever  heard." 

It  will  probably  be  best  to  quote  Dr  Baker's  own  summary  of 
his  paper.     He  says : — 

"  I.  Intermittent  fever  is  proportional,  directly  or  inversely,  to 
the  average  daily  range  of  atmospheric  tempei'ature. 

"  11.  The  controlling  cause  of  intermittent  fever  is  exposure  to 
insidious  changes,  or  changes  to  which  one  is  unaccustomed,  in  the 
atmospheric  temperature. 

"  IIL  In  the  mechanism  of  the  causation  of  intermittent  fever  the 
chief  factor  is  the  delay  in  the  reaction  from  exposure  to  cool  air. 
This  delay,  extending  to  a  time  when  greater  heat-loss  should 
occur,  results  in  the  abnormal  accumulation  of  heat  in  the  interior 
of  the  body,  and  in  disturbed  nervous  action — the  chill ;  and  the 


932  MALARIA.  [APRIL 

final  reaction  is  excessive  because  of  tlie  accumulation  of  heat,  and 
sometimes  because  it  occurs  at  the  warmest  part  of  the  day. 

"  IV.  The  fever  is  the  excessive  reaction  from  the  insidious  influ- 
ence of  the  exposure  to  cool  air,  and  it  is  periodical  because  of  the 
periodicity  of  nervous  action,  and  because  the  exposure  and  the  con- 
sequent chill  are  periodical  owing  to  the  nightly  absence  of  the 
warmth  of  the  sun. 

"  V.  Residence  in  valleys  or  in  low  lands,  through  which  or 
upon  which  cold  air  flows  at  night,  and  thus  causes  insidious 
changes  in  the  atmospheric  temperature,  favours  intermittent  fever. 

"VI.  In  our  climate  those  measures,  such  as  drainage,  which 
enable  the  soil  to  retain  warmth  during  the  night,  and  thus  reduce 
the  daily  range  of  temperature  immediately  over  such  soil,  tend  to 
decrease  intermittent  fever  among  residents  thereon. 

"  VII.  In  the  cure  and  prophylaxis  of  intermittent  fever  those 
remedies  are  useful  which  lessen  torpidity  and  tend  to  increase  the 
power  of  the  body  to  react  promptly  to  insidious  changes  in  atmos- 
pheric temperature. 

"  VIII.  The  slowness  of  the  pulse  and  other  indications  of 
torpidity  associated  with  the  retention  of  bile  or  with  certain  dis- 
turbances of  the  functions  of  the  liver  are  well  known  ;  but,  so  far 
as  known  to  the  writer,  these  conditions  have  not  heretofore  been 
considered  as  causative  of  the  fever  in  the  manner  herein  suggested." 

It  certainly  seems  that  the  well-known  clinical  and  pathological 
knowledge  which  is  possessed  of  malaria  cannot  be  reconciled  with 
Dr  Baker's  conclusions.  The  various  types  of  malaria  certainly  do 
not  fit  in  with  it.  If  the  chill  affected  the  nervous  system  and 
produced  periodicity  of  nervous  action  we  should  expect  that  the 
quotidian  type  of  fever  would  be  the  most  common,  whereas  it  is 
certainly  not.  Again,  the  well-known  facts  of  masked  malaria  or 
those  erratic  types  where  the  phenomena  of  the  seizure  are  reversed 
or  merely  local, — that  is  to  say,  one  part  of  the  body  being  solely 
afiiected,  can  they  surely  be  caused  by  an  insidious  chill  to  which 
the  whole  body  has  been  subjected  ?  Nor  is  it  possible 
to  understand  how,  if  malaria  is  caused  solely  by  chill,  it  can 
remain  latent  in  the  system  for  months  and  even  years.  Is  it 
possible  to  believe  that  a  simple  chill  could  so  alter  the  blood  that 
when  it  is  taken  from  a  person  suffering  from  malaria  and  injected 
into  the  body  of  a  person  free  from  it,  it  should  cause  ague  in  that 
person  ?  And  yet  Machiafava  and  Celli  have  proved  this  fact ;  and 
not  only  so,  but  they  have  proved  that  the  microscopical  appear- 
ances of  the  blood  of  the  person  so  infected  resemble  exactly  those 
appearances  seen  in  the  person  from  whom  the  blood  is  taken. 
Nor  do  we  think  that  the  chill  theory  can  explain  the  fact  that 
mothers  suffering  from  malaria  produce  children  with  enlarged 
spleens  and  suffering  from  malarial  cachexia. 

It  must  be  admitted  that  the  definite  cause  of  malaria  is  not  yet 
known,  and  therefore  we  are  glad  to  see  this  interesting  paper, 


1889.]  THE   OPERATIONS   OF   SURGERY.  933 

because  it  will  again  draw  attention  to  tliis  fact,  and  may  be  stimu- 
late investigators  to  further  research  with  reference  to  this  important 
subject. 

The  Operations  of  Surgery :  Intended  specially  for  the  Use  of  those 
recently  appointed  on  an  Hospital  Staff  and  for  those  preparing 
for  the  Higher  Examinations.  By  W.  H.  A.  Jacobson,  M.A., 
M.B.,  M.Ch.  Oxon.,  F.RC.S.,  Assistant  Surgeon,  Guy's  Hos- 
pital, Teacher  of  Operative  Surgery,  and  Joint  Teacher  of 
Practical  Surgery  in  the  Medical  School,  etc.  Pp.  1136.  With 
199  Illustrations.     London  :  J.  &  A.  Churchill :  1889. 

This  is  probably  the  largest  work  on  surgical  operations  in  the 
English  language,  luxuriously  printed  and  profusely  illustrated. 
The  preface  tells  us  it  aims  at  being  more  comprehensive  in  scope 
and  fuller  in  detail  than  those  already  published.  The  title-page 
tells  us  that  it  is  for  the  instruction  of  those  who  are  not  only  to 
operate  in  public,  but  to  instruct  others, — high  aims  and  a  diificult 
task.  The  specialities  are  not  interfered  with.  Ophthalmic,  aural, 
and  intra-laryngeal  operations  are  wisely  and  severely  let  alone ; 
but  gynaecological  operations,  as  distinct  from  obstetric  ones,  are 
fully  noticed.  The  only  obstetric  one  alluded  to  is  the  Csesarean 
section,  which  is  very  briefly  described. 

In  a  work  of  this  kind  originality  is  neither  expected  nor  desired. 
Judicious  selection,  accurate  yet  concise  description,  and  scientific 
arrangement,  are  chiefly  required.  This  work  contains  an  immense 
amount  of  excellent  material  culled  from  many  previously  existing 
manuals,  but  it  would  have  been  a  more  useful  work  had  more  time 
been  spent  on  making  it  shorter.  A  second  edition,  wisely  revised, 
could  be  much  reduced  in  size  by  shortening  descriptions  of 
anatomical  truisms,  by  making  abstracts  of  certain  surgical  cases, 
and  perhaps  by  selecting  the  best,  rather  than  describing  every 
method.  The  arrangement  of  the  whole  work  is  curiously  regional. 
Thus,  the  first  chapter  on  operations  on  the  hand  includes  amputa- 
tions, excisions,  webbed  fingers,  palmar  hgeniorrhage,  etc.  We 
find  the  account  (a  very  good  one)  of  transfusion  between  ununited 
fracture  of  olecranon  and  ligature  of  the  brachial  at  the  bend  of  the 
elbow.  Reinfusion,  the  scientific  method  suggested  by  Dr  John 
Duncan,  is  highly  commended. 

It  seems  to  us  that  by  taking  amputations  all  over  the  body  in 
one  chapter,  excisions  in  another,  ligature  of  vessels  in  another, 
much  recapitulation  is  saved,  and  information  wanted  is  more 
easily  got.  The  regional  method  of  arrangement  suits  admirably 
for  the  great  cavities,  skull,  thorax,  abdomen,  and  pelvis. 

Tracheotomy  is  a  test  subject  for  description,  and  we  find  a  very 
good  one  of  the  modes  of  operating,  dangers,  etc.  A  very  full 
account  is  added  about  the  after-treatment.  Indeed,  the  large  size 
of  the  book  is  partly  explained  by  the  manner  in  which  the  author 


934  THE   OPERATIONS   OF  SURGERY.  [APRIL 

has  taken  excursions  out  of  the  region  of  the  operation  into  the 
diagnosis,  arguments  for  and  against  operation,  and  tlie  after-treat- 
ment. We  are  far  from  blaming  him  for  doing  so.  Much  of  wliat 
he  says  is  valuable  and  interesting,  giving  the  views  of  the  great 
Guy's  School  on  many  important  subjects,  but  it  is  not  strictly 
Operative  Surgery. 

In  the  account  of  intubation  of  the  larynx  we  are  glad  to  see 
that  Dr  MacEwen  of  Glasgow  is  credited  with  the  original  idea. 

A  distinguished  surgeon  once  said  that  he  despaired  of  surgery 
ever  becoming  a  perfected  or  exact  science,  because  no  sooner  did 
one  man  discover  an  operation  or  a  method  of  treatment  that  was 
absolutely  perfect  (i.e.,  his  own),  than  some  one  else  tried  to  improve 
upon  it  and  spoilt  it.  Hydrocele  can,  in  the  great  majority  of 
cases,  be  cured  quickly,  safely,  and  pleasantly  by  the  injection  of  a 
suitable  quantity  ot"  the  Edinburgh  tincture  of  iodine.  Our  author 
"  injects  steadily  2  or  3  oz.  of  the  tincture  of  iodine  (Ed.  Pharma- 
copoeia)." Surely  he  means  drachms.  He  then  occupies  three 
pages  with  a  description  of  antiseptic  incision  and  drainage. 

For  piles  he  prefers  the  ligature  as,  on  the  whole,  the  best 
method,  but  the  other  methods  are  described  fully  and  carefully. 
The  description  of  excision  of  the  knee-joint  is  very  full,  and  in- 
cludes an  elaborate  discussion  as  to  whether  the  operation  is  justifi- 
able, and  in  what  cases  it  should  be  done.  The  author  inculcates  the 
views  of  Professor  Bruns  of  Tubingen,  that  every  morsel  of  granu- 
lation material  should,  if  possible,  be  got  away  at  the  operation. 

On  the  whole,  this  work  is  the  outcome  of  much  labour,  contains 
a  vast  amount  of  good  material,  and  will  repay  careful  study.  It 
is,  however,  in  many  ways  redundant,  and  trespasses  on  the 
domain  of  works  on  general  surgery,  and  is  in  some  respects 
deficient  in  precision,  and  does  not  always  guide  the  reader  to  a 
selection  of  the  best  out  of  the  many  methods  described.  The  best 
parts  are  those  which  describe  the  newest  and  most  recent  opera- 
tions, as  on  abdominal  organs.  Naturally,  and  quite  rightly,  the 
surgeons  of  Guy's  are  often  quoted  and  the  Guy's  practice 
described. 

When  the  author  is  older  he  will  shorten  the  work  by  omission 
of  many  alternative  methods,  and  still  more  by  not  describing  or 
recommending  new-fangled  instruments. 

The  work  is  liberally  supplied  with  diagrams  varying  much  in 
execution.  Some  are  the  well-known,  beautifully  delicate  woodcuts 
which  illustrated  Sir  Wm.  Fergusson's  work  on  Practical  Surgery. 
Others  are  fairly  executed,  but  about  as  useless  for  any  practical 
purpose  as  most  drawings  are.  Diagrams  which  are  merely  dia- 
grams to  illustrate  lines  of  incision  and  position  of  sutures  may  be 
very  instructive ;  drawings  of  the  stages  of  an  operation  are  nearly 
always  useless  and  misleading  in  proportion  to  their  artistic 
excellence. 


1889.]  MEMOIRS   AND   MEMORANDA   IN   ANATOMY,  ETC.  935 

Memoirs  and  Memoranda  in  Anatomy.  Vol.  I.  By  John  Cleland, 
M.D.,  Professor  of  Anatomy  in  the  University  of  Gla.sgow ;  JOHN 
TULE  Mackay,  M.D.,  Senior  Demonstrator  of  Anatomy  in  the 
University  of  Glasgow ;  and  R,  B.  YoUNG,  M.A.,  M.B.,  Demon- 
strator of  Anatomy  in  the  University  of  Glasgow.  Williams  & 
Norgate:  1889. 

These  memoirs  afford  very  satisfactory  evidence  of  the  large 
amount  and  high  character  of  the  original  work  which  is  being  done 
in  the  Anatomical  Department  of  the  Glasgow  University. 

The  papers  which  are  collected  into  this  volume  are  mostly  new, 
but  some  of  them  have  already  appeared  in  the  Transactions  of  the 
Philosophical  Society  of  Glasgow.  They  deal  with  various  subjects 
connected  with  human  and  comparative  anatomy.  Teratology 
occupies  rather  a  prominent  position.  Thus  Professor  Cleland  has 
an  article  on  "Teratology,  Speculative  and  Casual,  and  the  Classi- 
fication of  Anomalies,"  and  "  On  Birds  with  Supernumerary 
Legs."  Dr  Mackay  describes  cases  of  malformation  of  the  genito- 
urinary organs,  and  Mr  Young  treats  of  abnormal  arrangements  of  the 
intestines.  In  two  papers — one  on  the  form  of  the  human  skull  and 
the  other  on  that  of  the  pelvis— Professor  Cleland  deals  with 
subjects  on  which  he  is  a  well-known  authority,  and  holds  very 
decided  views.  He  has  very  little  faith  in  the  value  of  the 
numerical  indicis  associated  with  the  compounds  dolicho,  brachy, 
and  mesati,  which  are  now  so  commonly  employed  in  the  descriptions 
of  the  skulls  and  pelves  of  various  races. 

Dr  Mackay  has  several  interesting  communications  on  the  arterial 
system  of  various  animals,  and  Mr  Young  gives  some  interesting 
observations  on  the  structure  and  functions  of  the  knee-joint.  We 
hope  soon  to  see  another  volume  of  these  memoirs,  and  would 
suggest  that  in  it  an  attempt  should  be  made  to  classify  the  various 
papers. 

This  volume  contains  a  portrait  of  John  Goodsir  by  Professor 
Cleland,  who  in  a  note  states  that  "  the  portrait  at  the  commence- 
ment of  his  collected  works  is  not  in  the  least  degree  like  him :  it 
represents  a  feeble  old  man  with  a  little  chin.  But  Goodsir's  chin 
was  massive  and  in  keeping  with  his  tall  and  powerful  build, 
and  there  never  was  a  trace  of  mental  feebleness  in  his  face." 
Cleland  represents  him  in  the  dress  he  wore  at  an  introductory 
lecture. 

A  Handbook  of  Surface  Anatomy  and  Landmarks.  By  B.  C.  A. 
Wr.vDLE,  M.A.,  M.D.,  Professor  of  Anatomy  in  the  Queen's 
College,  Birmingham.     London  :  H.  K.  Lewis  :  1888. 

This  is  an  excellent  little  work,  and  it  deals  with  a  subject  of 
great  practical  importance,  but  one  that  is  very  apt  to  be  somewhat 
neglected  by  the  medical  student.  Holden's  Landmarks,  Medical 
and  Surgical,  deals  with  the  same  subject  in  a  very  similar  manner, 


936  A    HANDBOOK   OF   SUKFACE   ANATOMY,    ETC.  [aI'HIL 

80  that  there  does  not  appear  to  be  much  need  for  this  book, 
liolden's  charming  style  and  great  experience  as  a  teaciier  of 
anatomy  and  surgery  enabled  him  to  treat  the  subject  in  a  way 
that  left  little  to  be  desired.  Still  we  readily  acknowledge  tiiat 
Dr  Windle  has  done  his  work  well,  and  the  student  will  find  it  an 
accurate  and  reliable  guide. 


The  Formation  and  Excretion  of  Uric  Acid  considered  with  reference 
to  Gout  and  Allied  Diseases.  By  A.  Haig,  M.D.  Oxon., 
M.R.C.P.,  Thesis  for  the  Degree  of  M.D.  in  the  University  of 
Oxford.     London  :  John  Bale  &  Sons  :  1888. 

While  every  one  must  admit  that  the  employment  of  scientific 
methods  of  research  has  done  much  to  advance  our  knowledge  of 
medicine,  many  must  have  felt  that  in  the  hands  of  the  unscientific 
it  may  have  an  opposite  effect.  This  is  well  exemplified  in  the 
pamphlet  before  us. 

The  author  endeavours  to  connect  his  own  attacks  of  migraine 
with  the  presence  of  uric  acid  in  the  blood ;  and  from  this  passes  to 
consider  the  action  of  various  diets  and  drugs  upon  the  excretion  of 
this  effete  product.  He  concludes  from  observations  on  himself  that 
under  all  circumstances  the  uric  acid  production  is  to  the  urea  pro- 
duction as  1  to  33,  and  that  when  this  relationship  is  upset  it  is  due 
either,  on  the  one  hand,  to  a  retention  in  the  liver  and  spleen  of  some 
of  the  already  formed  uric  acid,  or,  on  the  other,  to  an  increased 
excretion.  The  diminished  proportion  on  a  flesh  diet  he  supposes  to 
be  due  to  such  a  retention,  although  he  has  not  considered  it  necessary 
to  investigate  if  this  actually  occurs.  After  a  prolonged  proteid  diet 
such  a  retention  must,  on  his  assumption,  be  very  excessive,  and 
should  be  easily  demonstrated,  even  by  rough  chemical  methods.  Are 
B-anke's  results,  and  is  the  small  excretion  of  uric  acid  in  carni- 
vorous animals  to  be  explained  on  this  assumption,  or  have  we  not 
rather  evidence  of  a  diminished  production  of  uric  acid  in  relation- 
ship to  urea?  But  such  a  view  would  not  suit  the  author's  theory 
in  regard  to  the  treatment  of  his  headaches. 

We  are  not  inclined  to  accept  his  observations  on  the  action  of 
various  drugs.  In  regard  to  the  salicylates,  we  should  not  only 
suspect  U  priori,  from  our  knowledge  of  the  mode  of  production  of 
salicyluric  acid  in  relationship  to  Horbaczewski's  chemical  demon- 
stration of  the  synthetic  production  of  uric  acid  from  glycin  and 
urea,  that  the  uric  acid  excretion  would  be  decreased  under  the 
salicylates ;  but  we  believe  that  Noel  Baton's  observations  on 
man  and  dogs  have  clearly  demonstrated  this  point.  In  regard  to 
colchicum,  too,  we  are  inclined  to  believe  that  the  conclusions  of 
the  last  named  investigator  are  legitimate,  and  that  an  increased 
production,  and  not,  as  Dr  Haig  supposes,  an  increased  excretion,  of 
uric  acid  occurs. 

In  regard  to  the  relationship  of  uric  acid   to  the  epileptic  fits 


1889.]  FORMATION   AND   EXCRETION   OF   URIC   ACID,   ETC.  937 

described,  the  author  forgets  that  there  is  good  evidence  that  any 
interference  with  the  proper  aeration  of  the  blood  will  increase  the 
production  and  excretion  of  uric  acid. 

His  theories  in  connexion  with  hypochondriasis  merely  show  how 
far  a  hobby  may  be  pushed.  All  recent  work  on  the  formation  of 
alkaloidal  poisons  during  digestion  is  simply  ignored.  Similarly 
all  chemical  investigations  in  connexion  with  the  appearance,  or 
rather  the  non-appearance,  of  an  excess  of  uric  acid  in  rheumatism, 
must  give  place  to  his  assumption  that  it  is  its  excess  in  the  blood 
which  produces  the  condition. 


Principles   of  Forensic  Medicine.     By  the  late  Dr  GuT,  and   Dr 
Fekriek.     Sixth  Edition.     London  :  Renshaw  :  1888. 

To  Dr  Ferrier  has  fallen  the  task  of  editing  this  edition  of  Dr 
Guy's  well-known  text-book.  This  manual  has  long  been  recog- 
nised as  the  best  existing  compendium  of  medical  jurisprudence  in 
the  language,  and  while  not  entering  into  competition  with  the  larger 
works  of  Taylor  and  Tidy,  it  still  holds  its  own  as  a  student's 
text-book,  in  which  the  facts  and  principles  of  the  science  are  clearly 
and  succinctly  stated  and  lucidly  arranged.  The  late  Dr  Guy 
possessed  the  happy  literary  knack  of  writing  a  text-book  in 
vigorous  English  and  in  short  compass,  and  all  that  his  colleague 
has  had  to  do  was  to  bring  the  various  topics  of  discussion  up  to 
date,  and  to  exercise  due  care  that  the  suitable  illustrations  were 
added.  This,  we  think,  Dr  Ferrier  lias  conscientiously  done,  and 
we  beg  to  congratulate  him,  amid  his  many  engagements,  that  he 
has  found  time  to  superintend  tiiis  improved  edition  of  a  work  by 
which  the  honoured  name  of  Guy  will  be  long  remembered  by 
students  and  the  profession. 


The  Studenfs  Handbook  of  Forensic  Medicine  and  Puhlic  Health. 
By  H.  Aubrey  Husband,  M.B.,  etc.  Fifth  Edition.  Edin- 
burgh :  E.  and  S.  Livingstone. 

The  fact  that  this  book  has  gone  through  so  many  editions 
must  be  taken  as  evidence  of  its  popularity  among  a  certain  class 
of  readers,  and  its  power  to  lend  a  helping  hand  to  students  about 
to  undergo  the  ordeal  of  examination. 

It  is,  however,  very  much  to  be  regretted  that  the  author,  in  the 
additions  which  have  been  made  to  the  last  two  editions,  has  not 
confined  them  rather  to  matter  extending  and  explaining  some  of 
the  very  importatit  subjects  which  have  received  but  scant  notice, 
than  to  the  introduction  of  (among  other  things)  formulae  such  as  are 
found  on  pages  519-522.  Any  one  going  so  deeply  into  the  sub- 
ject as  to  require  the  formulse  for  calculating  the  discharge  from 
weirs  and  sewers  would  assuredly  not  be  satisfied  with  the  short 
space  accorded  to  the  important  subject  of  the  disposal  of  sewage. 

EDINBURGH   MED.    JOURN.,    VOL.    XXXIV.— NO.    X.  6  C 


938  student's  handbook  of  forensic  medicine,  etc.       [APRIL 

The  ordinary  student  may,  liowever,  with  confidence  pass  over  the 
former  subject  so  far  as  the  needs  of  most  examinations  are  concerned, 
while  of  tlie  latter  lie  will  require  to  have  a  much  more  detailed 
knowledge  than  is  to  be  found  in  these  pages.  Perhaps  in  a  book 
embracing  two  such  subjects  as  Medical  Jurisprudence  and  Public 
Health  it  is  a  difficult  task  to  give  to  each  its  proper  share  of  space, 
but  one  cannot  help  feeling  a  certain  sense  of  dissatisfaction  at  finding 
the  same  amount  of  space  awarded  to  the  consideration  of  optical 
atmospheric  phenomena,  such  as  the  twinkling  of  stars,  twilight 
and  rainbows,  which  are  explained  in  every  text-book  of  physics, 
as  to  the  important  subject  of  Life  Assurance. 

The  type  is  good  and  clear,  and  the  general  get  up  of  the  volume 
leaves  nothing  to  be  desired. 


An  Illustrated  Encyclopcedic  Medical  Dictionary :  being  a  Dictionary 
of  the  Technical  Terms  used  by  Writers  on  Medicine  and  the 
Collateral  Sciences  in  the  Latin,  English,  French,  and  German 
Languages.  By  Frank  P.  Foster,  M.D.,  Editor  of  the  New 
York  Medical  Journal^  with  the  Collaboration  of  William 
C.  Ayres,  M.D.,  New  Orleans;  Edward  B.  Bronson,  M.D.,  New 
York;  Charles  Steedman  Bull,  M.D.,  New  York;  Henry  C. 
Coe,  M.D.,  etc.,  New  York  ;  Andrew  E.  Currier,  M.D.,  New 
York ;  Alexander  Duane,  M.D.,  New  York ;  Simon  H.  Gage, 
Ithaca;  Henry  J.  Garrigues,  M.D.,  New  York;  Charles  B. 
Kelsey,  M.D.,  New  York;  Russell  H.  Nevins,  M.D.,  New 
York;  Burt  S,  Wilder,  M.D.,  Ithaca,  N.Y.  Vol.  I.,  with 
Illustrations,  pp.  752.  London :  Thomas  Sealey,  Clark,  & 
Co.     New  York :  D.  Appleton  &  Co. 

This  first  volume  contains  letters  A  and  B,  and  a  few  pages  of 
C.  In  the  publisher's  circulars  we  are  told  it  is  to  be  finished  in 
three  more  volumes,  the  preparation  of  which  for  the  press  is  nearly 
complete.  When  finislied  it  will  be  a  work  of  extraordinary  value, 
for  in  completeness,  accuracy,  and  perfection  of  arrangement  it 
leaves  nothing  to  be  desired. 

Men  of  authority  in  each  department  have  been  selected.  Each 
signs  his  article  by  a  letter  which  is  enclosed  in  brackets,  and 
which  is  followed  in  many  cases  by  a  numeral,  which  refers  to  the 
authority  from  which  he  has  derived  his  information. 

All  strictly  medical  terms  which  have  been  current  at  any  period 
are  given;  their  meaning,  derivation,  equivalent  in  the  four  lan- 
guages, mode  of  pronunciation,  are  detailed  with  extraordinary 
care  and  preciseness.  No  reference  library  of  any  pretension  to 
completeness  can  afford  to  be  without  it ;  and  if  every  great 
publishing  house  had  a  copy,  the  labours  of  editors,  press  readers, 
and  even  compositors,  of  medical  works  would  be  greatly  lightened. 
Indeed,  when  it  is  finished,  bad  spelling  of  medical  words  and  abuse 
of  medical  terms  will  be  no  longer  venial  faults,  but  mortal,  because 


1889.]         AN    ILLUSTRATED    ENCYCLOPAEDIC    DICTIONARY,    ETC.  939 

presumptuoas,  sins.  No  one  who  has  not  seen  and  really  studied 
the  work  can  have  any  idea  of  the  herculean  character  of  the  task 
set  by  its  editor,  atid  in  process  of  accomplishment  by  himself  and 
his  coadjutors.  The  enterprising  publishers  deserve  success.  The 
book  is  a  dear  one,  and  is  to  be  issued  to  subscribers  at  £2,  5s.  per 
volume. 


The  Brooldyn  Medical  Journal,  February  1889. 

A  PAPER  on  the  "  Implantation  of  the  Teeth  of  Man  in  the  Jaws 
of  Man,"  by  Rodrigues  Ottolengui,  M.D.S.,  constitutes  the  first 
article  and  'pilce  de  resistance  of  the  February  number  of  this 
periodical.  So  many  departures  from  what  used  to  be  considered 
as  the  axioms  of  legitimate  surgery  have  of  late  years  occurred, 
that  much  of  what  was  once  so  designated  would  now  appear  to 
rank  among  the  superstitions  of  a  bygone  day.  The  implantation 
as  contrasted  with  the  transplantation  of  teeth  was,  however, 
unknown  in  those  unenlightened  times,  and  is  consequently 
altogether  an  innovation.  Transplantation  into  the  empty  socket 
was  a  mode  of  practice  in  which  dentists  in  those  days,  and  at 
somewhat  distant  intervals  ever  since,  have  "rushed  on  where 
surgeons  feared  to  tread;"  it  has  from  time  to  time  been  relinquished 
and  revived  again,  and  is  even  at  present  passing  through  one  of  those 
periods  of  resuscitation  and  popularity  of  which  time  and  experience 
alone  can  tell  the  result.  The  operation  of  implantation,  however, 
differs  somewhat  from  this  as  well  as  from  other  grafting  processes, 
inasmuch  as  it  requires  a  considerable  amount  of  injury  to  be 
inflicted  upon  healthy  structures  for  the  reception  of  a  whole  organ 
removed  from  the  body  of  another  individual.  One  of  the  textures 
requiring  to  be  so  treated  in  this  instance  by  boring  into  it,  is  bone, 
one  or  other  maxilla,  and  the  tendency  of  bone  lesions  to  induce 
pyemic  complications  would  suggest  caution  in  any  procedure  of 
the  kind;  while  the  implantation  of  any  organ  from  one  human 
body  to  another  seems  equally  to  require  care  as  to  possible  con- 
stitutional results.  The  practice  of  transplantation  is,  as  we  have 
said,  an  old  one,  as  not  long  after  John  Hunter's  experiments  in  it, 
legal  proceedings  were  not  unknown  against  practitioners,  at  the 
instance  of  the  victim  who  had  supplied  the  necessary  teeth;  and  it 
is  not  long  since  the  death  of  an  old  dentist  in  Edinburgh  occurred, 
whose  recollection  extended  to  a  case  of  the  kind,  where  a  dentist  in 
the  then  fashionable  Canongate  district  was  sued  by  the  father  of  a 
girl  under  age  from  whom  some  tooth  or  teeth  had  been  bargained 
for  and  extracted  to  be  used  in  this  way.  The  operation  of 
implantation,  again,  as  described,  and  more  particularly  as  witnessed, 
appears  a  painful  one,  but  its  success  in  many  instances  cannot  be 
denied.  Possibly  more  of  the  successes  than  of  the  failures  are 
heard  of;  and  it  is  at  all  events  questionable  whether,  unless  in 
very  exceptional  cases,  such  an  operation  should   be  resorted  to. 


940  THE   BROOKLYN   MEDICAL  JOURNAL,    ETC.  [APRIL 

Its  general  adoption,  liowever,  may  be  safely  left  to  the  test  of 
experience ;  and  for  those  who  wish  to  put  it  on  its  trial,  tlie  paper 
under  review  is  very  well  worthy  of  perusal  as  containing  much 
information  and  very  explicit  instructions  for  the  operator. 

This  number  of  the  Journal  also  contains  several  other  valuable 
and  interesting  contributions. 


The  Asdepiad  for  First  Quarter  1889.  Vol.  VI.  By  Benjamin 
Ward  Eichardson,  M.D.,  F.R.S.  Pp.  100.  London  :  Long- 
mans; Green,  &  Co. 

This  magazine,  probably  unique  in  liaving  only  one  contributor, 
who  is  also  its  editor,  maintains  its  high  standard  of  originality 
and  good  writing.  Its  leading  article  is  the  paper  read  before  the 
Medical  Society  of  London  on  10th  December  1889,  "On  the 
Absolute  Signs  and  Proofs  of  Death."  It  practically  exhausts  the 
subject.  In  historical  interest  and  fulness  of  detail,  in  a  masterly 
analysis  of  the  various  proofs  of  death  differing  so  much  in  value, 
it  is  a  model — clear,  precise,  and  well  arranged.  The  most  careless 
reader  cannot  fail  both  to  be  interested  and  instructed.  Tiie  other 
papers  are  up  to  the  usual  high  standard  of  the  journal.  The 
biographical  notice  of  Joseph  Priestley  is  enriched  by  a  beautiful 
autotype  of  an  engraving  by  W.  Hole  of  his  portrait  by  Gilbert 
Stewart. 


The  Year-hook  of  Treatment  for  1889.     London,  Paris,  New  York, 
and  Melbourne :  Cassell  and  Co.,  Ltd. 

This  annual  is  now  in  its  fifth  year  of  issue.  It  maintains  its 
higb  character  and  reputation,  and  is  as  indispensable  as  ever  to 
the  practitioner  of  medicine. 


The  Scots  Observer,  a  Record  and  a  Review. 

Eighteen  numbers  have  now  appeared  of  this  spirited  young 
weekly,  which  bids  fair  to  be  at  once  the  Spectator  and  the  Satur- 
day Review  of  Scotland.  Admirably  printed  on  good  paper,  it 
gives  a  record  of  the  events  of  the  week,  and  a  review  of  what  is 
newest  and  best  in  literature  and  art.  It  has  a  special  flavour  of 
Scotch  sport  and  Scotch  history.  One  of  its  chief  features  is  a 
weekly  pen  and  ink  portrait  of  a  "  Modern  Man."  As  a  rule  these 
have  been  brilliantly  written.  One  appreciative  notice  of  Dr 
Thomas  Keith  will  have  a  special  interest  to  our  readers. 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  941 

MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY    OF    EDINBURGH. 

SESSION   LXVIII. — MEETING  V. 
Wednesday,  6th  February  1889. — Dr  John  Smith,  President,  in  the  Chair. 

I,  Election  of  Ordinary  Members. 

John  Smith,  M.D.,  16  Townsend  Crescent,  Kirkcaldy;  Allan  C, 
Sym,  M.D.,  144  Morningside  Eoad ;  and  Edmund  Price,  M.B., 
CM.,  28  Mayfield  Eoad,  were  elected  Ordinary  Members  of  the 
Society. 

II.  Exhibition  of  Instruments. 

Professor  Annandale  exhibited  instruments — (1.)  In  connexion 
with  Intubation  of  the  Air-passages,     (2.)  A  new  bone-drill. 

III.  Exhibition  of  Specimens. 

1.  Mr  A.  G.  Miller  exhibited  a  sigmoid  flexure  which  caused 
death  by  volvulus.  The  patient,  M.  H.,  set.  18,  had  her  bowels 
moved  on  31st  December  twice.  Previous  history  of  constipation 
and  occasional  colicky  attacks.  On  1st  January  seized  with  pain 
suddenly,  referred  to  umbilicus,  and  very  severe.  Vomiting 
occurred  almost  at  once,  and  frequently  on  way  home ;  felt  better 
after  a  while,  and  went  out  to  a  party.  Constipation  persistent ; 
vomiting  ceased  after  3rd  January  till  9th  January,  never  fsecal  or 
severe  ;  abdomen  distended  and  tympanitic,  and  slightly  sensitive. 
Injections  did  not  pass  beyond  rectum.  Nothing  to  be  felt  by 
finger  in  rectum.     No  appearance  of  collapse  till  9th  January. 

Treatment. — Opium-meat  suppositories ;  rectal  enemata. 

Operation  on  9th  January  1889.  Incision  from  umbilicus  to 
pubes ;  no  protrusion  of  bowel.  Sigmoid  flexure  greatly  distended 
and  lying  over  into  right  lumbar  and  iliac  regions ;  also  twisted  on 
itself  quite  half  a  turn. 

Explanation  of  Mechanism  of  Twist. — Sigmoid  mesentery  un- 
usually long  and  narrow.  Bowel  somewhat  constricted  at 
junction  with  descending  colon  and  with  rectum.  At  latter 
point  is  a  distant  fold  with  commencing  stricture.  Obstruc- 
tion was  at  once  relieved  by  undoing  the  twist.  Bowels  acted 
freely,  colon  emptying  itself  while  patient  on  table.  Patient 
did  well  for  two  days.  At  10  p.m.  on  Friday  the  11th,  patient  was 
suddenly  seized  with  pain,  became  collapsed,  and  died  before  mid- 
night. 

Post-mortem  on  loth  January. — No  peritonitis.  Obstruction 
re-established  with  great  distension  of  sigmoid,  which  was  doubled 
back  on  the  descending  colon. 


942  MKETINGS   OF   SOCIETIES.  [APRIL 

2.  Dr  Lundie  exhibited — (a.)  united  fracture  of  neck  of 
FEMUR.  The  patient,  a  lady,  then  aged  71,  met  with  an  accident 
about  four  years  ago,  by  falling  on  the  carpet  in  her  room. 
Immediately  there  was  pain  and  powerlessness  of  the  limb.  Dr 
Duncan  and  he  (Dr  Lundie)  saw  her.  There  were  all  the  usual 
symptoms  of  unimpacted  intracapsular  fracture  of  the  femur. 
They  decided  to  put  her  up  with  long  splint  and  extension.  After 
six  weeks  the  bone  appeared  to  be  firmly  united.  He  was  sorry 
afterwards  he  did  not  leave  the  limb  perfectly  free  after  that; 
for  to  make  assurance  doubly  sure  he  put  on  a  starch  bandage ; 
and  while  it  was  on  the  patient  had  a  bad  carbuncle,  and  after 
recovering  from  that,  was  a  considerable  time  in  regaining  the 
power  of  the  muscles  of  the  limb.  In  the  course  of  a  year  or  so 
she  had  as  good  use  of  the  limb  as  she  had  had  before.  That 
continued  till  a  short  time  before  her  death.  He  was  fortunate 
enough  to  get  a  post-mortem,  and  removed  the  specimen.  He 
was  not  prepared  to  commit  himself  as  to  where  exactly  the 
fracture  had  been.  It  looked  to  him  as  if  it  had  passed  through 
the  upper  surface  of  the  neck.  The  neck  had  certainly  been  very 
much  shortened,  and  on  the  articular  surface  of  the  head  they 
would  see  an  indication  of  change  of  angle  between  the  neck 
and  the  shaft  of  the  femur.  The  head  had  been  previously  set 
in  more  at  right  angles  than  it  is  at  present.  If  the  fracture  had 
been  an  impacted  one,  certainly  it  had  not  any  of  the  symptoms 
of  it  at  the  time.  Specimens  were  also  exhibited  from  the  same 
patient,  showing  how  a  simple  tumour  may  lead  to  a  malignant 
one.  A  hard  tumour,  recognised  during  life,  was  found  at  the 
post-mortem  to  be  a  scirrhus  developed  in  one  (right)  of  two 
cystic  ovarian  tumours.  (h.)  Fish  bone  removed  from  the 
(ESOPHAGUS.  Dr  Lundie  said  there  was  nothing  remarkable 
about  the  bone  (the  clavicle  of  a  haddock.  If  in.  long).  It  had, 
however,  shrunk  somewhat,  and  did  not  look  so  formidable  as 
when  brought  out.  The  reason  he  showed  it  was  that  he  might 
call  attention  to  a  serious  imperfection  in  the  instrument  by 
which  it  was  removed.  He  was  sent  for  to  see  a  young  woman 
who  had  been  eating  some  fish  in  a  great  hurry,  when  she  felt  the 
bone  stick  in  her  pharynx.  She  swallowed  a  piece  of  bread  to 
try  to  get  it  down ;  and  after  doing  so  felt  a  sharp  pain  at  the 
level  of  the  xiphoid  cartilage  instead.  It  seemed  to  him  that  the 
bone  had  wounded  the  lower  end  of  the  oesophagus ;  and  as  the 
pain  had  come  on  each  time  she  had  swallowed  for  nearly  thirty 
hours,  he  thought  there  was  a  strong  probability  that  the  bone 
was  still  there.  He  intended  to  try  to  remove  it  with  an  ex- 
panding probang,  but  found  that  while  the  oesophagus  is  nine  or 
ten  inches  long,  the  instrument  was  only  eleven  inches,  so  that 
there  was  only  an  allowance  of  one  or  two  inches  for  mouth  and 
pharynx.  Dr  Aitken's  instrument  was  the  same  as  Dr  Lundie's, 
and  he  suggested  an  extemporized  addition  to  it.     The  bone  was 


1889.]  MEDICO-CHIRUKGICAL   SOCIETY   OF   EDINBURGH.  943 

brought  up.  It  seemed  curious  that  makers  should  go  on  from 
generation  to  generation  making  an  instrument  four  or  five 
inches  too  short  to  effect  completely  the  purpose  for  which  it  is 
intended. 

IV.  Original  Communications. 

1.  Mr  Charles  W.  Cathcart  read  a  paper  on  sites  for  amputa- 
tion IN  THE  LOWER  LIMB  IN  RKLATION  TO  ARTIFICIAL  SUBSTITUTES, 
which  appeared  at  page  819  of  this  Journal. 

Dr  Joseph  Bell  said  that  the  Society  was  much  gratified  with  the 
paper.  While  not  agreeing  in  every  respect  with  the  conclusions 
of  the  previous  paper,  he  entirely  agreed  with  everything  Mr  Cath- 
cart said  with  regard  to  the  conservation  of  parts.  It  struck  him 
that  one  of  the  instrument  makers  had  grasped  the  root  of  the 
matter.  It  gave  him  the  impression  tliat  instrument  makers  could 
do  almost  anything  with  the  stump  if  the  cicatrix  was  well  out  of 
the  way.  When  he  alluded  to  the  cicatrix  being  well  out  of  the 
way,  he  seemed  to  know  how  important  it  was  for  the  flap  to 
have  no  visible  cicatrix.  If  you  get  a  flap  with  a  well-healed  unat- 
tached cicatrix,  and  if  you  get  the  cicatrix  out  of  the  way,  either 
behind  or  front,  so  as  not  to  be  pressed  upon  by  the  places  in  the 
artificial  limb  where  the  weight  is  borne,  then  it  does  not  matter, 
and  you  ought  to  save  as  much  as  possible  of  the  patient's  body. 
He  thought  that  if  the  cicatrix  were  kept  off  the  bone,  the 
instrument  maker  was  able  to  make  a  limb  which  practically  was 
very  nearly  if  not  equally  as  good  as  the  sound  one,  but  it  was 
necessary  that  the  cicatrix  should  be  perfect  and  loose.  Dr  Bell  then 
referred  to  his  method  of  amputation  in  lower  third  of  the  leg  by 
a  long  anterior  flap,  and  alluded  to  a  case  of  a  man  treated  twent}'- 
five  years  ago,  who  was  till  lately  working  as  a  railway  porter  with 
a  limb  which  could  not  readily  be  distinguished  from  the  sound 
one.  He  had  never  been  asked  to  amputate  any  lower  limb 
above  the  ankle  because  the  flap  seemed  too  long.  He  had  often 
amputated  a  limb  because  the  cicatrix  had  been  either  adherent 
or  was  in  a  bad  position. 

Professor  Annandale  thought  surgeons  should  keep  themselves  en- 
tirely independent  of  instrument  makers'  opinions.  The  duty  of  the 
surgeon  is  to  amputate  the  limb  or  portion  of  it  in  order  to  get  rid 
of  disease  or  injury,  and  to  save  as  much  as  possible  of  the  limb. 
It  does  not  matter  from  what  position  he  gets  the  flap,  provided  it 
is  one  which  will  properly  cover  the  bone.  In  connexion  with 
his  own  amputations  he  entirely  ignored  instrument  makers' 
opinions,  and  what  Dr  Cathcart  had  said  showed  that  they  could 
provide  a  useful  artificial  limb  whether  the  stump  was  long  or 
short.  He  thought  Dr  Cathcart  had  given  too  much  prominence 
to  one  instrument  maker  in  London,  and  he  suggested  that  the 
name  should  be  suppressed  if  the  paper  was  published. 

Br  Cathcart  said  he  appreciated  Professor  Annandale's  sugges- 


944  MEETINGS   OF   SOCIETIES.  [aPKIL 

tioii.  He  had  the  permission  of  the  makers  to  use  their  names, 
and  he  proposed  to  <i;ive  a  reference  to  them,  so  that  it  might  not 
seem  that  he  had  invented  the  answers  they  had  given  him.  He 
was  much  interested  in  working  at  this  subject.  Strong  assertions 
had  been  made  by  men  who  had  professedly  a  great  deal  of 
experience,  that  they  could  do  better  for  the  patients  if  the 
surgeons  took  off  more.  It  was  right  they  should  go  thoroughly 
into  these  assertions,  and  he  had  come  to  the  conclusion  that  they 
should  save  as  much  as  they  could.  Still,  it  was  satisfactory  to 
know  their  reasons  for  it. 

2.  Professor  Annandale  read  a  paper  on  acute  intussusception 

IN    A    CHILD    THKEE    YEAKS    OF    AGE,    SUCCESSFULLY    BELIEVED    BY 

ABDOMINAL  SECTION,  which  appeared  at  page  777  of  this  Journal. 

Dr  Bell  said  he  was  sure  that  the  feelings  of  the  members  of  the 
Society  would  be  that  the  case  was  an  admirable  one.  There 
could  not  have  been  a  more  precise  and  perfect  example  of  what 
those  cases  ought  to  be.  He  thought  that  the  treatment  explained 
was  the  best  and  only  mode.  Sometimes,  even  in  the  most 
fortunate-looking  cases,  the  result  is  not  always  so  good.  He 
was  called  upon  to  attend  a  little  girl  where  the  symptoms 
were  precisely  the  same.  He  felt  from  the  rectum  the  csecal 
tumour,  and  opened  the  abdomen.  It  was  easy  to  reduce  the 
small  intestine  without  trouble  or  difficulty.  Unfortunately 
the  child  died.  It  was  under  the  care  of  an  able  man.  There 
were  no  adhesions  to  any  of  the  other  parts  of  the  intestinal 
canal.  He  thought  he  was  right  in  saying  that  in  many  children 
who  died  from  diarrhcea,  three  or  four  intussusceptions  may  be 
found  on  post-mortem  examination,  each  apparently  having  formed 
in  the  later  stages  shortly  before  death,  and  probably  such 
secondary  intussusceptions  may  cause  death  in  the  fatal  cases, 
even  after  operation  has  relieved  the  first  one. 

Dr  Duncan  joined  in  Dr  Bell's  observations  upon  the  value  of 
the  record  of  the  case  mentioned  by  Professor  Annandale.  It 
belonged  to  that  class  in  which  the  diagnosis  was  undoubted,  and 
was  therefore  suitable  for  operation.  Dr  Duncan  referred  to  a 
recent  case  where  the  post-mortem  revealed  peritonitis,  there 
having  been  all  the  symptoms  of  sudden  and  complete  obstruction. 
The  diagnosis  was  exceedingly  difficult  in  many  of  those  cases. 
In  children  they  had  constantly  a  tumour  at  the  rectum,  and  in 
the  case  referred  to  the  intussusception  took  place  lower  down. 
The  only  case  of  intussusception  in  a  very  young  child  in  which  he 
performed  laparotomy  was  one  in  which  all  other  things  had  been 
tried  without  success.  The  case  was  exceedingly  interesting  in 
various  respects, — first  in  regard  to  the  fact  that  the  intussusception 
had  taken  place  of  the  small  intestine  into  the  large,  and  the  piece 
of  bowel  had  traversed  the  whole  of  the  colon  until  it  could  be  felt 
at  the  rectum.     It  was  not  very  common  to  have  not  only  one. 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  945 

but  double  intussusception  into  the  caecum.  The  interesting  point 
in  the  case,  however,  was  that  he  found  the  greatest  possible 
assistance  in  reducing  the  bowel  successfully  by  pressure  as  well 
as  stretching.  Steady  pressure,  such  as  is  done  in  reducing  hernia, 
was  of  great  assistance  in  pulling  the  bowel  out.  The  operation 
was  a  long  and  tedious  one.  The  child  died  of  shock  within 
twelve  hours.     The  mortality  in  these  cases  is  always  high. 

Professor  Annandale,  in  reply,  thanked  Mr  Duncan  for  his 
remarks,  and  again  emphasized  the  fact  that  cases  of  acute  intus- 
susception in  children  were  most  fatal.  When  an  early  operation 
is  performed,  the  reduction  is  comparatively  easy,  and  he  expressed 
his  opinion  about  the  importance  of  the  early  operation.  Of 
course  one  must  expect  in  all  forms  of  intestinal  obstruction  to 
meet  with  a  complication.  He  had  seen  the  other  day  an  interest- 
ing case  of  a  woman  in  the  last  stage  of  intestinal  obstruction. 
She  had  been  examined  previously  by  several  of  his  colleagues, 
who  were  of  opinion  that  there  was  some  obstruction  in  the  small 
intestine.  Under  chloroform,  a  tight  malignant  stricture  of  the 
rectum  was  discovered.  The  sigmoid  flexure  of  the  colon  was 
then  exposed  with  the  view  of  performing  inguinal  colotomy,  but 
as  this  gut  was  found  collapsed,  a  dilated  portion  of  the  small 
intestine  was  seized  and  stitched  to  the  wound  so  as  to  make 
an  artificial  anus  above  the  obstruction.  The  patient  died  two 
days  after,  and  at  the  post-mortem  a  very  small  strangulated 
obdurator  hernia  was  found.  The  portion  of  intestine  which  pro- 
truded and  was  strangulated  did  not  include  the  whole  circum- 
ference of  the  bowel,  and  was  scarcely  a  quarter  of  an  inch  in 
length. 


OBSTETRICAL  SOCIETY  OF  EDINBURGH. 

SESSION   L. — MEETING  III. 

Wednesday,  9th  January  1889. — Dr  FouLis,  Vice-President,  in  the  Chair. 

I.  Br  Foulis  showed — (a.)  his  new  aspirator  syringe,  and  de- 
scribed how  it  could  be  used  as  a  syphon  and  as  a  stomach-pump. 
Its  great  advantage  was  that  at  all  times  the  operator  had  perfect 
control  over  the  suction  process.  It  was  possible  to  hasten  or 
slow  the  flow  of  fluid  into  the  exhausted  bottle  at  the  will  of 
the  operator,  and  all  danger  of  injuring  delicate  tissues  during 
aspiration  was  thus  avoided.  (6.)  His  improved  glossotilt, 
and  demonstrated  how  it  could  be  used,  both  in  the  adult  and  in 
the  child,  as  a  means  of  raising  the  hyoid  bone  and  the  epiglottis 
and  aryteno-epiglottic  folds  at  one  and  the  same  time.  It  was 
quite  impossible  to  carry  out  artificial  respiration  properly  when 
the  mouth  was  closed,  as  in  forced  respiratory  efforts  through  the 
nares  obstructive  valving  of  the  nasal  flaps  was  sure  to  occur. 
Dr  Foulis  bent  back  the  neck  and  the  head  on  the  atlas  vertebra 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    X.  6  D 


946  MEETINGS   OF   SOCIETIES.  [APRIL 

as  the  first  step  to  the  introduction  of  the  glossotilt,  which  could  be 
introduced  with  the  greatest  ease  both  in  the  adult  and  child. 

II.  Dr  Halliday  Groom  showed  TWO  CYSTS — blood  cysts  OF 
OVARY — from  a  lady  aged  40.  The  entire  ovarian  tissue  had  been 
destroyed,  and  nothing  remained  of  the  ovaries  on  either  side  .but 
old  clots  contained  within  a  thin  cyst  wall.  The  condition,  like 
that  of  a  former  specimen  he  had  shown,  was  associated  with 
frequent  miscarriage  in  early  married  life,  and,  later,  with  irregular 
haemorrhage  and  much  pelvic  pain. 

III.  Dr  Freeland  Barbour  read  a  NOTE  ON  Saxinger's  frozen 
SECTION  FROM  THE  FIRST  STAGE  OF  LABOUR,  which  will  appear  in  a 
future  number  of  this  Journal. 

IV.  Br  Johnson  Symington  read  his  paper  on  the  normal 
ANATOMY  OF  THE  FEIVLALE  PELVIC  FLOOR,  which  appeared  at  page 
788  of  this  Journal. 

V.  Dr  Berry  Hart  read  his  paper  ON  the  aim  and  scope  of  the 

STRUCTURAL  ANATOMY  OF  THE  FEMALE  PELVIC  FLOOR. 

Prof.  Simpson  thought  the  three  papers  which  had  just  been 
read  were  all  extremely  interesting,  and  Dr  Symington's  especially 
would  form  a  very  valuable  contribution  to  their  Transactions. 
The  Society  and  obstetricians  generally  were  under  a  debt  of 
gratitude  to  him  for  the  fresh  observations  he  had  made  and  the 
clear  exposition  he  had  given  of  the  result  of  his  frozen  sections  of 
the  pelvis.  He  (Prof.  Simpson)  hoped  Dr  Symington  would  have 
the  opportunity  of  making  further  sections,  perhaps  of  the  pelves 
of  younger  women,  and  would  again  favour  the  Society  with  a 
record  of  his  researches.  As  Dr  Hart  had  indicated,  it  would  add 
to  the  value  of  such  investigations  to  have  the  sections  made  in 
different  directions,  so  as  to  get  various  views  of  the  structure  and 
relations  of  the  pelvic  floor.  Much  of  the  contention  between  Dr 
Symington  and  Dr  Hart  lay  in  the  difference  of  definition.  The 
structure  and  relations  remain  the  same  whether  with  Dr  Symington 
we  limit  the  term  "  floor  "  to  the  firm,  resistant  structures  closing 
the  pelvic  outlet  and  attached  to  its  bony  and  ligamentous 
margins,  or,  with  Dr  Hart,  include  in  the  term  the  viscera  that 
are  closely  bound  to  them  by  their  peritoneal  investment.  Dr 
Symington's  paper  was  especially  important  in  giving  us  a  clearer 
impression  of  the  relation  of  the  firm  part  of  the  pelvic  floor  to  the 
anterior  wall  of  the  pelvis  ;  but  as  regards  the  vagina,  the  descrip- 
tion of  the  behaviour  of  its  walls  in  labour  given  by  Dr  Hart 
seemed  to  be  correct,  that  the  anterior  wall  moves  mainly  upwards 
and  the  posterior  mainly  downwards  during  the  descent  of  the 
fcetal  head.  It  seemed  somewhat  arbitrary  to  place  the  vagina 
partly  in  the  pelvic  floor  and  j)artly  in  the  pelvic  cavity ;  and  if 
this  was  to  be  done,  it  would  be  necessary  to  define  what  portion 
of  it  was  diaphragmatic  and  what  was  visceral. 


I 
I 


1889.]  OBSTETRICAL   SOCIETY   OF   EDINBURGH.  947 

Dr  Halliday  Groom  expressed  his  appreciation  of  the  papers 
which  had  been  read.  He  was  of  opinion  that  the  inference 
drawn  from  sectional  anatomy  from  frozen  cadavera  or  portions  of 
cadavera  had  been  carried  beyond  what  the  sections  themselves 
warranted.  In  any  case,  he  believed  it  certainly  to  be  the  case 
that  much  too  general  conclusions  had  been  drawn  from  the  ex- 
amination of  a  limited  number  of  specimens.  Dr  Symington's 
paper  was  full  of  interest,  and  so  far  as  he  (Dr  Groom)  could  judge 
of  an  anatomical  subject  described  for  the  first  time,  he  was 
entirely  in  accord  with  Dr  Symington.  Dr  Symington's  pelvic 
floor  seemed  to  him  a  definite  and  fixed  body,  with  clear  relations. 
Upon  it  lay  the  pelvic  viscera — bladder,  uterus,  and  rectum.  He 
could  not  imagine  a  floor  with  such  varying  relations  as  that  described 
by  Dr  Hart,  containing  as  it  did  an  ever  filling  and  emptying 
bladder  and  rectum.  Dr  Hart  had  claimed  that  his  floor  was  a 
clinical  floor.  That  Dr  Hart  had  described  the  behaviour  of  the 
pelvic  contents  during  labour  was  one  thing,  but  to  describe  a 
definite  anatomical  floor  was  quite  another.  Dr  Hart  had 
attempted  the  one,  and  Dr  Symington  the  other.  The  whole  dispute, 
so  far  as  he  could  see,  was  merely  a  matter  of  words.  If  Dr  Hart 
would  discard  his  true  floor,  and  speak  of  the  behaviour  of  pelvic 
contents  during  labour,  and  if  Dr  Symington  would  leave  labour 
alone,  he  believed  both  conflicting  views  could  be  satisfactorily 
arranged.  If  it  was  to  remain  a  question  of  pelvic  floor,  then  he 
entirely  agreed  with  Dr  Symington,  whose  pelvic  floor  seemed  to 
him  to  be  a  really  solid  structure,  containing  above  it  the  bladder, 
uterus,  and  rectum.  He  could  not  conceive,  from  an  anatomical 
point  of  view,  a  floor  of  such  varying  relations  as  that  which  Dr 
Hart  had  described. 

Dr  Milne  Murray  did  not  wish  to  discuss  in  any  detail  the  very 
interesting  papers  which  had  been  read,  but  desired  to  draw  atten- 
tion to  a  certain  point  in  Dr  Hart's  criticism  of  Dr  Symington's 
method  of  investigation.  Dr  Hart  was  of  opinion  that  Dr  Syming- 
ton's method  of  investigation  was  faulty,  in  that  Dr  Symington  did 
not  make  his  sections  in  a  "  definite  direction."  But  it  seemed  to 
Dr  Murray  that  it  was  unfair  to  limit  the  method  of  investi- 
gation by  any  such  restriction.  And,  further,  Dr  Hart  claimed 
that  the  direction  in  which  he  made  his  sections  (parallel  with  the 
axis  of  the  brim)  was  the  most  satisfactory,  because  this  was  the 
line  of  entrance  of  the  foetal  head.  But  it  should  be  remembered 
that  the  foetal  head  passes  through  the  pelvic  floor  in  a  very  different 
direction  to  this  ;  and,  as  a  matter  of  fact,  Dr  Symington's  sections 
were  much  nearer  the  correct  direction,  even  on  Dr  Hart's  own 
showing. 

Dr  Barbour  had  been  greatly  impressed  by  Dr  Symington's 
paper,  which  gave  the  results  of  much  valuable  original 
work.  "What  had  struck  him  most  was  the  demonstration  of  the 
firm  attachment  of  the  anterior  portion  of  the  pelvic  floor  under 


948  MEETINGS   OF   SOCIETIES.  [APRIL 

the  pelvic  arch.  This,  however,  was  not  incompatible  with  mobility 
of  the  rest  of  this  portion.  To  use  Dr  Hart's  illustration  of  the 
folding-door,  this  was  the  fixed  part  of  the  hinge  on  which  the 
door  turned.  There  was,  undoubtedly,  a  portion  of  the  floor  which 
moved  upwards  in  labour,  viz.,  the  upper  part  of  the  anterior 
vaginal  wall,  with  the  adjacent  portion  of  the  cervix,  the  cellular 
tissue  between  it  and  the  bladder,  and  the  utero- vesical  peritoneum, 
which  limited  this  part  of  the  floor  above. 

Dr  Symington  stated,  in  reply  to  the  objection  of  Dr  Hart  that 
his  transverse  sections  were  in  no  definite  direction,  whereas  they 
ought  to  be  axial  coronal,  or  in  the  line  of  the  pelvis,  that  the 
floor  was  not  in  the  same  place  as  the  inlet  of  the  pelvis,  and 
axial  coronal  sections  would  therefore  divide  it  obliquely.  The 
axis  of  the  anterior  part  of  the  floor  was  nearly  horizontal,  and  he 
had  divided  it  nearly  at  right  angles.  Dr  Hart  had  further  main- 
tained that  axial  coronal  sections  were  those  that  ought  to  have 
been  made,  since  during  labour  the  floor  was  pressed  against  in 
that  direction.  Dr  Milne  Murray  had  disposed  of  that  view  by 
showing  that,  although  the  foetal  head  entered  the  pelvis  in  the 
axis  of  the  pelvic  inlet,  yet  that  it  altered  its  direction  before  it 
reached  the  pelvic  floor.  Dr  Symington  admitted  that  he  had  had 
some  difficulty  with  regard  to  the  relation  of  the  vagina  to  the 
pelvic  floor ;  still  he  believed  that  he  was  right  in  describing  its 
lower  part  as  in  the  floor,  and  the  upper  portion  above  it.  It  was 
only  the  lower  portion  that  could  be  constricted  by,  or  that  came 
into  relation  with  the  levatores  ani.  The  upper  part  of  the  vagina, 
being  above  the  floor,  was  very  movable,  and  this  facilitated  the 
physiological  changes  in  the  position  of  the  uterus.  Dr  Symington 
had  endeavoured  to  investigate  the  anatomy  of  the  pelvic  floor  in- 
dependent of  any  clinical  theories,  and  he  felt  bound  to  differ  from 
Dr  Hart's  description  of  the  anatomical  connexions  of  the  pubic 
and  sacral  segments.  He  had  shown  that  the  pubic  segment  lying 
below  the  bladder  was  firmly  attached  to  the  pubes,  and  Dr  Hart 
had  not  attempted  to  prove  his  statement  that  the  sacral  segment 
had  a  firm  dove-tailed  attachment  to  the  sacrum  and  coccyx. 

Dr  Berry  Hart  considered  Dr  Symington's  paper  a  most  valuable 
one.  His  demonstration  of  the  relation  of  the  vagina  to  the  vulva 
and  of  the  condition  of  the  anus  was  a  distinct  advance  in  anatomy. 
As  to  Dr  Symington's  criticisms  of  his  own  views  on  structural 
anatomy,  he  did  not  consider  them  valid.  Dr  Symington's  coronal 
sections  were  not  made  in  any  definite  axis,  were  not  parallel  to 
one  another,  and  could  therefore  hit  or  miss  important  relations.  In 
his  first  section  Dr  Symington  nearly  cleared  the  retro- pubic  fat,  and 
then  cut  beneath  the  pubic  arch.  This  demonstrated  the  attachment 
of  the  pubic  segment  there  ;  but  Dr  Hart  had  figured  a  better 
section  already,  showing  how  the  muscles  of  the  perineum  blended 
and  surrounded  the  urethra  and  vagina  there.  Dr  Hart  had  never 
asserted  that  the  pubic  segment  was  entirely  loose  in  its  attach- 


1889.]  OBSTETRICAL  SOCIETY   OF   EDINBUKGH.  949 

ment.  It  was  certainly  loosely  attached  anteriorly,  posteriorly,  and 
laterally.  All  gynaecologists  knew  that  in  prolapsus  uteri  the  dis- 
placement ceased  at  the  pubic  arch,  and  that  the  end  of  the  urethra 
was  fixed  there.  Yet  Dr  Symington  held  that  this  one  firm 
attachment  made  the  whole  segment  a  fixed  one.  Then  Dr 
Symington  maintained  that  the  sacral  segment  was  not  strongly 
dove-tailed  into  the  sacrum.  This,  liowever,  was  not  only  shown 
in  Dr  Hart's  mesial  sections,  but  also  in  a  lateral  sagittal  one.  As 
to  what  was  pelvic  floor,  that  depended  on  the  point  of  view. 
From  a  clinical  point  of  view,  the  pelvic  floor,  canalized  during 
labour,  was  bounded  above  by  the  peritoneum.  Dr  Symington's 
idea  of  the  pelvic  floor  was  of  no  use  clinically  in  labour,  and  was 
a  bad  one  anatomically,  inasmuch  as  it  divided  the  vagina,  at  any 
rate,  and  excluded  it  from  the  pelvic  floor.  Dr  Symington  con- 
tended that  the  bladder  was  not  part  of  the  pelvic  floor,  but  one 
could  not  divide  the  pubic  segment  up  in  this  way  owing  to  the 
firm  attachment  of  urethra  and  vagina.  There  seemed  to  him  no 
other  explanation  of  the  abdominal  position  of  the  bladder  than 
the  one  he  had  first  advanced,  viz.,  that  the  pubic  segment  was 
drawn  up  in  part.  Not  only  was  there  a  displacement  upwards  of 
the  bladder,  but  also  of  the  retro-pubic  fat  and  peritoneum. 


ROYAL  MEDICAL  SOCIETY. 


Feh.  22.— A.  L.  Gillespie,  M.B.,  in  the  Chair.  A.  R  Stoddart, 
M.B.,  showed — (1.)  The  Sigmoid  Flexure  of  the  Colon  from  a 
woman.  While  on  the  switchback  railway  patient  felt  a  pain  in 
the  left  side,  and  shortly  afterwards  a  swelling  appeared  at  the 
same  place.  This  subsided,  but  ten  days  afterwards  reappeared, 
and  was  attended  with  vomiting.  The  condition  was  diagnosed  as 
volvulus  of  the  sigmoid  flexure,  and  the  diagnosis  confirmed  on 
operation  by  Mr  A.  G.  Miller.  The  volvulus  was  reduced,  but 
returned,  and  patient  died  of  collapse.  (2.)  Kidneys  in  an 
advanced  condition  of  destruction  from  Tubercular  Pyelo- 
nephritis. Several  months  previously,  an  incision  had  been  made 
for  lumbar  abscess ;  but  it  was  only  three  weeks  before  death  that 
any  ureemic  symptoms  appeared.  A.  L.  Gillespie,  M.B.,  communi- 
cated a  case  of  Tyrosinuria,  which  had  a  fatal  termination.  A.  J. 
Whiting  read  a  dissertation  on  Sympathies. 

March  1. — H.  H.  Littlejohn,  M.B.,  in  the  Chair.  H.  O.  Huie 
read  a  dissertation  on  Dyspnoea. 

March  8.— E.  C.  Carter,  M.B.,  in  the  Chair.  H.  H.  Littlejohn, 
M.B.,  showed  a  patient  suffering  from  marked  deformity,  the  result 
of  Chronic  Rheumatic  Arthritis  of  both  hip-joints.  Also,  the  Brain 
of  a  woman,  aged  30,  who  died  of  compression  caused  by  the  rup- 
ture of  one  of  the  large  veins  in  the  brain  membranes,  over  the 
right    superior    frontal    convolution.      The    rupture    completely 


950  MEETINGS   OF   SOCIETIES.  [APRIL 

divided  the  comparatively  large  vessel,  and  one  of  the  ends  was 
filled  by  a  small  clot.  The  surrounding  area  was  covered  by  a 
dark,  firm  clot,  a  large  amount  of  blood  having  been  effused.  It  was 
at  first  thought  that  her  husband  had  assaulted  her,  both  having 
been  drunk  and  quarrelling  the  night  before,  but  the  injury  was 
proved  to  have  been  caused  by  a  fall,  which  had  bruised  the  head 
over  the  occiput,  the  rupture  of  the  vein  being  at  the  point  of 
contre-coup.  Patient  for  long  had  been  of  drunken  habits,  and  all 
the  viscera  were  in  a  more  or  less  diseased  condition.  No  marked 
atheroma  was  detected  in  the  cerebral  vessels,  but  the  probability 
is  that  they  were  undergoing  degeneration  owing  to  her  dissipated 
habits  of  life.  H.  H.  Littlejohn  showed  the  Stomach  of  a  man  who 
committed  suicide  by  swallowing  a  quantity  of  butter  of  antimony. 
Death  resulted  in  a  short  time,  and  was  probably  due  not  so  much 
to  the  irritative  action  of  the  poison  on  the  stomach  as  to  the 
specific  action  of  the  antimony  on  the  system.  Some  of  the 
common  tests  for  antimony  were  exhibited.  B.  A.  Fleming,  M.B., 
read  a  dissertation  on  Glycosuria. 

March  15. — E.  C.  Carter,  M.B.,  in  the  Chair.  A.  J.  Whiting 
read  a  communication  on  a  case  of  Nervous  Disease  of  doubtful 
nature.  It  had  been  diagnosed  as  cerebro-spinal  sclerosis,  loco- 
motor ataxia,  Friedreich's  hereditary  ataxia,  "  obscure  tremors," 
and  malingering,  by  different  physicians  in  the  Infirmary.  Patient, 
a  man,  aged  23,  complained  of  shaking  of  head,  body,  and  limbs  of 
six  years'  duration.  His  family  history  was  distinctly  neurotic,  com- 
prising alcoholism,  epilepsy,  and  imbecility  in  different  members. 
He  was  a  pedlar  by  trade,  and  had  led  a  very  hard  life,  with  irregular 
meals,  poor  food,  and  constant  exposure  to  the  weather  when  not 
in  hospital.  No  history  of  syphilis  was  obtained.  During  con- 
valescence at  the  age  of  9  from  scarlet  fever,  "  gastric  "  fever,  and 
whooping-cough,  which  occurred  in  rapid  succession,  trembling  of 
the  legs  began,  and  never  entirely  disappeared.  Eight  years  later, 
after  an  attack  of  typhoid  fever,  he  was  unable  to  move  any  part 
of  his  body  except  the  head.  Subsequently,  tremors  and  loss  of 
co-ordination  were  noticed  in  all  the  limbs,  speech  was  impaired, 
and  there  were  shooting  pains  in  the  legs,  and  occasional  jerkings 
while  patient  was  sitting  quietly  in  a  chair.  A  sensation  of 
formication  was  experienced,  and  at  various  times  double  vision 
and  visual  and  auditory  hallucinations  were  complained  of.  In 
addition,  physical  examination  revealed  the  following : — (I),  Nys- 
tagmus ;  (2),  loss  of  sense  of  smell,  with  retention  of  common 
sensibility  of  nasal  mucosa ;  (3),  drawling,  scanning  speech  ;  (4), 
vertigo  ;  (5),  exaggeration  of  reflexes  ;  (6),  spastic  gait ;  (7),  acquired 
mental  impairment.  Patient  also  displayed  a  rachitic  chest,  and 
absence  of  the  lower  half  of  left  pectoralis  major.  The  cause  of 
the  latter  might  either  be  congenital  deficiency  or  acquired  atrophy 
from  a  patch  of  sclerosis.  The  patient  was  shown,  and,  by  the 
kindness  of  Dr  Bramwell,  sections  of  spinal  cord  with  insular 


1889.]  ROYAL  MEDICAL   SOCIETY.  951 

sclerosis  were  demonstrated  microscopically.  A.  L.  Turner  showed 
photographs  of  a  case  of  Fatty  Tumour.  F.  D.  Boyd,  M.B.,  read  a 
dissertation  on  Meniere's  Disease. 

March  20. — H.  H.  Littlejohn,  M.B.,  as  Senior  President,  delivered 
the  Valedictory  Address. 


t^art  ,iroutit)» 


PERISCOPE. 

MONTHLY  REPORT  ON  THE  PROGRESS  OF  THERAPEUTICS. 

By  William  Craig,  M.D.,  F.R.S.E.,  Lecturer  on  Materia  Medica,  Edinburgh 
School  of  Medicine,  etc.,  etc. 

PiCROTOXiN  IN  Epilepsy. — Dr  Annie  News  reports  a  case  {New 
York  Medical  Journal)  of  the  cure  of  epilepsy  by  picrotoxin.  The 
patient,  aged  fourteen,  had  been  for  six  months  affected  with  petit 
mal.  The  attacks  had  increased  in  number,  his  intellect  was 
getting  impaired,  and  he  had  begun  to  get  a  slight  idiotic  look. 
Picrotoxin  -ixs  gr.  four  times  daily  had  a  rapid  effect.  In  a  few 
weeks  the  attacks  ceased.  The  remedy  was  gradually  withdrawn, 
and  after  five  years  the  attacks  had  not  recurred,  and  the  boy 
did  well  at  school. — Duhlin  Journal  of  Medical  Science^  December 
1888. 

Nitro-Glycerine. — Professor  Munasseine  (Vratch)  has  been 
trying  the  effects  of  nitro-glycerine  in  nephritic  cases,  and,  from  a 
number  of  observations,  concludes  that  nitro-glycerine  diminishes 
the  amount  of  albumen  passed  in  the  twenty-four  hours ;  the  amount 
of  urine  passed  is  increased  in  the  twenty-four  hours,  and  this 
increase  is  maintained  for  some  time  after  the  cessation  of  the  drug 
(L'  Union  Medicale,  No.  135). — Duhlin  Medical  Journal^  December 
1888. 

Pyrodine  :  A  New  Antipyretic. — The  last  addition  to  the 
list  of  modern  antipyretics  bears  the  name  of  pyrodine,  and  contains 
as  its  active  ingredient  acetyl-phenyl-hydrogen,  its  formula  being 
CgH5N2H2(02H30).  Pyrodine  appears  to  be  a  more  powerful 
antipyretic,  both  in  degree  and  rapidity  of  action,  than  antifebrin, 
antipyrin,  or  phenacetin.  The  reduction  of  temperature  lasts 
several  hours,  followed  by  a  slight  rise,  and  then  a  second  spon- 
taneous reduction,  so  that  the  action  of  a  single  dose  may  last  an 
entire  day.  The  reduction  of  temperature  is  accompanied  by 
profuse  sweating,  but  collapse,  vomiting,  or  nausea  do  not  appear 
to  be  noted,  even  when  the  reduction  of  temperature  may  be  4°  C. 
The  doses  employed  were  from  3  to  4  grains  given  to  children,  8 
to  12  grains  to  adults.  Dr  Dreshfeld  sums  up  the  results  of  his 
investigation  as  follows  {Medical  Chronicle^  November  1888) : — 1. 


952  PERISCOPE.  [APRIL 

Pyrodine  is  a  powerful  antipyretic.  2.  It  reduces  fever  tempera- 
ture quickly,  and  maintains  the  temperature  at  a  low  level  for 
some  hours.  3.  It  is  easily  taken,  and  produces  marked  perspira- 
tion, but  no  nausea,  vomiting,  or  collapse.  4.  It  is  especially 
applicable  in  cases  of  pneumonia,  scarlet  fever,  and  typhus.  Given 
in  small  doses  in  the  latter  disease,  it  enables  the  patient  to  pass 
through  the  fever  period  at  a  lower  temperature  range  without 
delaying  the  crisis,  and  it  seems  also  to  shorten  the  period  of 
convalescence.  5.  It  is  less  applicable  in  cases  of  typhoid,  owing 
to  the  early  exhibition  of  toxic  symptoms.  6.  It  appears  to  act 
equally  well  in  migraine  and  neuralgia,  though  on  this  point 
observations  are  as  yet  not  numerous  enough  to  admit  of  a  definite 
opinion.  7.  Given  in  often-repeated  doses  at  short  intervals,  it 
easily  shows  toxic  properties,  and  these  depend  on  the  action  of 
the  drug  on  the  blood,  producing  hsemoglobiiisemia.  It  should  not 
be  given  (unless  the  temperature  be  very  high)  oftener  than  once 
in  eighteen  or  twenty-four  hours,  and  it  is  not  safe  to  continue  its 
use  for  more  than  a  few  days.  8.  It  is  found  to  act  in  cases  where 
the  other  antipyretics  have  failed.  9.  The  dose  for  children  is  2 
to  4  grains ;  for  adults,  8  to  12  grains.  10.  It  is  a  much  more 
powerful  antipyretic  than  either  antipyrin,  antifebrin,  or  phenacetin, 
but  it  is  also  much  more  toxic  than  these  bodies.  This  disadvantage 
is,  however,  reduced  by  the  fact  that  it  is  rarely  necessary  to  give  more 
than  one  dose  in  twelve  to  eighteen  hours,  as  the  temperature  is 
kept  low  for  a  longer  period  than  if  any  of  the  other  antipyretics 
are  given.  11.  It  reduces  the  pulse  as  well  as  the  temperature, 
and  often  causes  diuresis.  Experiments  made  by  Dr  R.  Wild  as  to 
the  physiological  action  of  pyrodine  show  that  it  has  no  effect  on 
voluntary  muscle,  and  but  little  on  the  isolated  heart  of  the  frog. 
It  causes  dilatation  of  the  bloodvessels  by  acting  on  the  spinal 
cord  and  not  on  the  vessels  directly.  It  has  a  paralyzing  action 
on  the  central  nervous  system. — Therapeutic  Gazette,  January 
1889. 

Papain  as  a  Digestive  Ferment. — Dr  Grineritshi  highly 
recommends  the  employment  of  papain  in  dyspeptic  conditions 
characterized  by  an  habitual  failure  of  digestion,  by  acid  eructa- 
tions, and  by  the  painful  symptoms  of  gastric  fermentation.  He 
administers  in  such  cases  10  to  15  centigrammes  of  papain  (Finkler) 
mixed  with  25  to  30  centigrammes  of  sugar  of  milk.  This  dose  is 
taken  an  hour  or  two  after  food  in  a  tablespoonful  of  an  alkaline 
mixture  containing  bicarbonate  of  sodium,  carbonate  of  ammonium, 
carbolic  acid,  and  glycerine.  Dr  Grineritshi  states  that  the  pain 
due  to  acid  fermentation  is  by  this  treatment  completely  relieved, 
the  excess  of  acid  being  neutralized  as  digestion  proceeds.  He 
considers  that  papain  is  without  a  rival  as  a  digestive  ferment,  and 
reports  the  cure  by  its  use  of  the  most  obstinate  cases  of  chronic 
dyspepsia,  even  though  associated  with  pain  and  with  constipation 


1889.]  MONTHLY    KEPOIIT    ON    THEKAPEUTICS.  953 

of  the  bowels.  The  above  treatment  is  of  course  accompanied  hy 
the  usual  dietetic  and  general  hygienic  directions  (Bulletin  Gen&al 
de  Therapeutique). — Glasgow  Medical  Journal,  January  1889. 

The  Internal  Employment  of  Iodol. — Dr  V.  Martini  has 
employed  iodol  in  cases  of  chronic  bronchitis  and  other  chronic 
pulmonary  affections  in  the  iiospital  at  Sienne,  substituting  it  for 
the  iodide  of  potassium ;  and  has  stated  that  the  elimination  of  the 
iodide  is  slower,  and  its  therapeutic  effects  are  more  persistent. 
This  would  therefore  seem  to  indicate  the  superiority  of  iodol  over 
iodide  of  potassium  {Revue  Generale  de  Clinique  et  de  TMrapeutique, 
November  8,  1888). — Therapeutic  Gazette,  January  1889. 

MousSENA  :  A  New  T^nicide. — M.  Thiel  has  discovered  in  the 
bark  of  a  leguminous  plant,  described  by  Bail  Ion  under  the  name 
of  Acacia  anthelmintica,  a  substance  whose  chemical  characteristics 
closely  resemble  those  of  saponine  (Moussenine).  The  author 
states  that  this  bark  is  much  more  active  as  a  taenicide  than  kousso, 
and  is  less  disagreeable  to  the  taste.  He  has  employed  it  in  the 
form  of  a  powder  in  a  dose  of  from  10  to  16  drachms,  mixed  with 
honey  or  milk,  or  it  may  be  employed  in  infusion,  of  which  an 
ounce  may  be  taken  as  a  dose,  given  in  the  morning  two  or  three 
hours  before  eating.  In  the  evening  of  the  same  day,  or  in  the 
morning  or  evening  of  the  day  following  the  tsenicide,  the  parasites 
will  usually  be  displaced,  followed,  after  a  few  days,  with  removal 
of  their  fragments  {Journal  de  Medecine  de  Paris,  November  11, 
1888). — Therapeutic  Gazette,  January  1889. 

Boric  Acid  in  Intermittent  Fever. — For  the  last  three  years 
Dr  BouchRloff  {Bulletin  General  de  T/i&apeutique,  September  3rd, 
1888)  has  been  employing  boric  acid  in  doses  of  5  drachms,  once 
or  twice  daily,  in  the  treatment  of  malarial  fever.  In  the  great 
majority  of  cases  he  claims  that  this  remedy  will  completely  replace 
quinine,  although  in  certain  cases  he  was  compelled  to  resort 
to  some  preparation  of  quinine. — Therapeutic  Gazette,  January 
1889. 

A  Case  of  Sciatica  Treated  with  Large  Doses  of  Anti- 
febrin. — Dr  Austin  Flint  reports  in  the  New  York  Medical  Record, 
December  1,  1888,  a  case  of  long  continued  sciatica,  which,  after 
failure  of  packing  the  limb  for  thirty-six  hours  in  the  flowers  of 
sulphur,  nerve-stretching,  and  other  remedies,  was  cured  in  forty- 
eight  hours  by  giving  antifebrin  to  the  limit  of  physiological 
tolerance.  The  first  day  fifty  grains  were  given  within  four  hours, 
and  the  patient  became  somewhat  cyanotic  and  weak,  but  was 
relieved  by  a  dose  of  whisky.  The  second  day  forty  grains  were 
given  in  two  hours.  The  third  day  the  pain  was  completely  gone, 
and  the  patient  walked  without  difficulty. — Therapeutic  Gazette, 
January  1889. 

EDINBURGH   MED.   JOURN.,   VOL.   XXXIV. — NO.   X.  6  B 


954  PERISCOPE.  [apkil 

MEDICAL  PEKISCOPE. 
By  Francis  Tkoup,  M.D. 

Berlin.  Klin.  Wochenschr.,  No.  1,  1889. — Dr  Vogel  of  Freiburg 
relates  a  case  of  spontaneous  cure  of  an  abdominal  aneurism,  which 
was  certified  to  be  such  by  Esmarch  and  Neuber  of  Kiel,  who  had 
observed  the  case  for  two  months.  The  patient  returned  from  tlie 
clinique  there  to  his  home  in  a  much  worse  condition  than  when 
he  left  for  hospital  treatment  there.  The  cure  took  place  without 
any  surgical  or  medical  appliances,  and  was  so  complete  in  the  space 
of  one  year,  that  the  patient  was  able  to  work  at  wood  cutting,  and 
after  six  years  there  was  no  recrudescence  of  symptoms :  pulsation 
and  tumour  had  disappeared,  and  patient  had  no  complaint,  and 
was  able  for  hard  labour. 

Ibidem. — Engelmann  of  Kreuznach  discusses  the  question 
whether  tuberculosis  is  transmissible  by  living  in  rooms  where 
tubercular  cases  have  been  treated  and  died,  and  comes  to  the  con- 
clusion that  it  may. 

Ibidem. — Rosenbach  of  Breslau  describes  a  peculiar  pigmentary 
reaction  of  the  urine  in  severe  intestinal  affections  of  different  kinds. 
The  reaction  is  brought  about  in  the  following  way.  The  urine  is 
boiled  and  nitric  acid  added  during  boiling  to  it  till  a  deep  Bur- 
gundy red  colour  is  obtained.  In  characteristic  cases,  after 
addition  of  perhaps  10-15  drops  of  the  acid,  a  sudden  effervescence 
takes  place,  and  the  red  changes  into  red-yellow  and  then  into 
yellow.  Careful  neutralization  with  ammonia  causes  after  the 
addition  of  each  drop  a  blue-red  precipitate,  wiiich  redissolves,  and 
at  last  a  flesh-red  changing  into  red-brown  colour  of  the  liquid  is 
brought  about  and  remains  constant.  Clinically  Rosenbach  con- 
siders that  this  reaction  indicates  bowel  diseases  which  have  this 
in  common,  a  disturbance  of  resorption  in  the  whole  intestinal 
canal.  The  reaction  is  never  missed  in  cases  of  occlusion  of  the 
bowel,  and  seems  to  be  a  sure  sign  of  bowel  cancer;    it  is  also 

? resent  in  abscess  connected  with  the  bowel  and  in  severe  diarrhoeas, 
n  cases  of  obstruction  of  the  bowels  where  the  reaction  has  been 
constantly  found,  Rosenbach  has  never  seen  a  satisfactory  result. 
In  the  original  article,  it  is  also  pointed  out  wherein  the  reaction 
diflfers  from  the  indigo  one. 

Ibidem,  and  Nos.  2  and  3. — Eulenburg  of  Berlin  contributes 
papers  on  the  symptomatology  and  therapeutics  of  Basedow's  disease. 
In  addition  to  the  well-known  symptom  triad,  he  alludes  to  certain 
concurrent  phenomena  of  more  or  less  constancy.  1st,  Graefe's 
symptom,  viz.,  defective  consensus  between  the  movements  of  the 
upper  lid  and  the  elevation  and  depression  of  the  visual  plane. 
This  seems  to  him  to  be  caused  by  disturbance  of  some 
central  mechanism  which  regulates  the  associated  movements 
of  the  levator-palpebrse  sup.  and  orbicularis,  and  combines  them 
with  those  of  the  ocular  muscles  which  turn  the  eye  on  its  hori- 


1889.]  MEDICAL   PERISCOPE.  955 

zontal  axis.  The  position  of  this  centre  is  unknown,  "but  will  prob- 
ably be  found  in  the  neighbourhood  of  other  oculo-motor  nuclei. 
He  finds  this  symptom  in  about  43  per  cent,  of  his  cases,  2nd, 
Stellwag's  symptom,  viz.,  the  almost  complete  abrogation  of  the 
spontaneous,  involuntary  winking  which  helps  to  moisten  the 
eyeball,  and  whose  absence  brings  about  a  tendency  to  xer- 
ophthalmus. This  symptom,  to  be  looked  upon  as  a  failure  of  the 
sensory  nerves  of  conjunctiva  and  cornea  to  excite  the  periodical 
contraction  of  the  orbicularis,  is  rarer  than  the  Graefe  one.  3rd, 
Another  disturbance  of  ocular  motility  is  the  weakness  or  short 
duration  of  convergence  movements  (Moebius).  4th,  Tremulous- 
ness.  Charcot  and  Marie  have  lately  directed  attention  to  this 
overlooked  or  little  noticed  symptom,  although  it  is  so  common 
that  Charcot  considers  it  one  of  the  "chief  symptoms,"  and  adds  it 
as  a  fourth  to  the  well-known  triad.  This  trembling  differs  much 
from  that  of  other  chronic  nerve  affections  (disseminated  sclerosis, 
paralysis  agitans,  senile  trembling,  and  that  of  intoxications).  Like 
the  trembling  of  purposed  movements  (Intentionszittern)  it  disap- 
pears during  repose,  and  becomes  exaggerated  by  slight  psychical 
excitement.  The  tremor  often  spreads  over  a  great  part  of  the 
body,  particularly  its  upper  part.  The  frequency  of  the  move- 
ments is  tolerably  great,  being,  according  to  Marie,  8-9  oscillations 
per  second.  Rosenbach  next  refers  to  the  painless  watery  diar- 
rhoeas, the  alterations  in  the  skin,  heat,  reddening,  taches  cer^brales, 
erythemata  and  urticarise  and  sclerema,  hyperidrosis,  limited  to  one 
side  "  ephidrosis  unilateralis,"  pigmentary  anomalies,  and  to  the 
lessened  resistance  to  the  galvanic  current.  As  to  therapeutics, 
Eulenburg  speaks  of  the  beneficial  results  of  residence  in  elevated 
regions,  helped  also  by  balneo-therapeutical  and  electrical  pro- 
cedures. He  lays  special  stress  on  the  Weir-Mitchell  method  of 
administering  nutriment,  and  also  on  the  use  of  milk  and  kefir.  He 
also  has  a  good  word  for  the  "  thirst "  or  "  dry"  cure,  in  which  the 
nourishment  consists  almost  entirely  of  dry  bread.  All  those 
methods  of  cure  cannot  be  carried  out  in  private  houses,  and  there- 
fore patients  must  go  to  special  nerve  institutions,  a  long  list  of 
which  he  gives. 

Ibidem,  Nos.  3  and  4. — Riitimeyer  of  Basle  relates  at  great 
length  a  case  of  primary  lung  actinomycosis.  The  patient  was 
under  observation  from  the  beginning  of  her  illness  till  her  death. 
In  the  latent  stage  there  are  indefinite  lung  symptoms,  cough  and 
scanty  expectoration,  and  occasional  feelings  of  tightness  and  op- 
pression of  chest.  The  under  portion  of  the  lung  seems  to  be  often- 
est  affected,  the  apex  remaining  unimplicated.  The  diagnosis  is 
certain  if  actinomyces  are  found  in  the  sputa.  The  second  stage  is 
accompanied  by  fever  and  specific  inflammation  of  pulmonary 
and  costal  pleura  and  pericardium,  and  afterwards  contraction  of 
lung,  and  extension  of  the  disease  to  the"  chest  walls  and  mediastina. 
In  the  third   stage  fever  continues,  and  abscess  cavities  form   in 


956  PERISCOPE.  [APRIL 

lungs  and  mediastina.  The  sputa  are  often  bloody  for  days,  but 
seem  different  from  phthisical  sanguinolent  expectoration  in  this, 
that  the  blood  is  intimately  mixed  with  a  glassy,  jelly  sort  of  mucus, 
very  like  the  raspberry  sputum  of  malignant  lung  tumours. 
Death  was  preceded  by  dropsy,  great  cardiac  debility  and  cachexia. 
The  treatment  of  the  case  was  chiefly  surgical,  but  kreosote  was 
believed  to  have  a  beneficial  effect,  internally  administered,  and 
also  injected  into  the  thoracic  actinomycotic  foci. 


PERISCOPE  OF  STATE  MEDICINE. 

By  J.  Allan  Gray,  M. A.,  M.D.  Edin.,  F.R.C.P.E. 

Case  of  Suicide  with  Numerous  Wounds. — Prof,  von  Moscha, 
in  the  Pragcv  Medieinische  Wochenschrift,  communicates  the  case  of 
a  man,  aged  51,  who,  after  a  residence  of  two  months  in  an  insane 
asylum,  had  apparently  so  far  recovered  as  to  be  entrusted  with  a 
knife  for  the  purpose  of  cutting  an  apple.  In  the  night  following 
he  was  found  covered  with  numberless  wounds,  from  which  blood 
was  abundantly  flowing,  and  died  the  succeeding  evening. 
Amongst  other  wounds,  more  than  200  were  found  on  the  left  side 
of  the  chest,  50  on  the  inner  side  of  the  left  forearm,  and  28  small 
wounds  on  the  inner  side  of  the  right  forearm.  The  left  radial  and 
ulnar  arteries  were  divided.  On  section,  six  of  the  wounds  on  the 
left  side  of  the  chest  were  found  to  have  penetrated  the  thorax 
through  the  intercostal  muscles  ;  but  there  was  no  injury  to  the 
ribs  or  sternum,  nor  to  the  heart  or  pericardium.  Blood  was  found 
in  the  left  pleural  cavity,  compressing  the  lung,  which  was  other- 
wise uninjured.  Blood  was  likewise  effused  into  the  anterior 
mediastinum,  and  on  the  fat  deposited  on  the  pericardium.  The 
wounds  were  caused  by  a  small  bladed  knife.  Death  resulted  from 
haemorrhage. — Medical  and  Surgical  Reporter,  10th  Nov.  1888, 
p.  591. 

Sewerage  and  Drainage,  with  brief  reference  to  Disposal 
OF  THE  Sewerage  of  Philadelphia. — Under  this  heading  Dr  J.  M. 
Anders  discusses  at  some  length  the  various  well-known  methods 
of  disposing  of  sewerage  as  in  use  in  connexion  with  large  cities. 
He  concludes  his  paper  by  advocating  the  adoption  of  the  "separate" 
system  for  Philadelphia,  and  gives  for  this  the  following  reasons : 
— "  First,  It  separates  the  more  dangerous  elements  of  sewerage 
from  the  larger  portion  of  refuse  products  and  stormwater — a 
point  of  the  first  importance  in  the  minds  of  leading  sanitarians. 
Secondly,  It  accomplishes  the  speedy  and  effective  removal  of  the 
more  hurtful  portion  of  sewage  before  putrefactive  decomposition 
can  take  place,  and  consequent  contamination  of  the  house  atmo- 
sphere. Thirdly,  The  removal  of  the  sewage  constituents  other 
than  human  excrement,  though  harmful  if  allowed  to  decompose, 
can  yet  be  more  safely  left  to  the  old  sewers,  which  would  continue 


1889.]  PERISCOPE   OF   bTATE   MEDICINE.  957 

to  be  flushed  by  the  same  natural  agencies  as  those  of  the  present 
time.  Fourthly,  The  fact  that  the  superficial  area  is  already 
extensive  and  constantly  increasing,  while  some  of  the  sewers  are 
even  now  inadequate,  furnishes  additional  basis  in  favour  of  the 
adoption  of  the  system  here  advocated.  Fifthly,  By  utilizing  the 
old  sewers  the  "  separate "  system  could  be  introduced  for  a 
moderate  outlay,  while  the  benefit  derived  by  the  community 
would  be  an  ample  return." — Philadelphia  Medical  Times,  vol. 
xviii.,  p.  485,  1888. 

Disinfection   and    Disinfectants. — The    Committee   on   Dis- 
infectants of  the  American  Public  Health  Association  announce 
as  the  results  of  their  investigations  that  the  most  useful  agents 
for  the  destruction  of  spore-containing  infectious  material  are : — 
(1),   Fire,   complete   destruction   by    burning;    (2),   Steam   under 
pressure,  105°  C.  (221°  Fahr.)  for  ten  minutes  ;  (3),  Boiling  in  water 
for  half  an  hour ;  (4),  Chloride  of  lime  (containing  at  least  25  per 
cent,  of  available  chlorine),  a  4  per  cent,  solution ;  (5),  Mercuric 
chloride,  a  solution  of  1  in  500.     For  the  destruction  of  infectious 
material  which  owes  its  infecting  power  to  the  presence  of  micro- 
organisms not  containing  spores,  the  Committee  recommend : — 
(1),  Fire,  complete  destruction  by  burning ;  (2),  Boiling  in  ivater 
for  ten  minutes;  (3),  Dry  heat,  110°  C.  (230°  Fahr.)  for  two  hours ; 
(4),    Chloride   of  lime,  a  2    per   cent,   solution ;    (5),  Solution   of 
chlorinated  soda  (should  contain  at  least  3  per  cent,  of  available 
chlorine),  a  10  per  cent,  solution ;  (6),  Mercuric  chloride,  a  solution 
of  1   in  2000 ;    (7),   Carbolic  acid,  a  5  per   cent,  solution ;    (8), 
Sidphate  of  copper,  a  5  per  cent,  solution ;  (9),  Chloride  of  zinc,  a 
10  per  cent,  solution ;  (10),  Sidphur  dioxide  (this  will  require  the 
combustion  of  between  3  and  4  pounds  of  sulphur  for  every  1000 
cubic  feet  of  air  space),  exposure  for  12  hours  to  an  atmosphere 
containing  at  least  4  volumes  per  cent,  of  this  gas  in  presence  of 
moisture.     Founding  on  these  observations,  the  Committee  make 
several  useful  recommendations  regarding  the  practical  application 
of  these  agents  for  disinfecting  purposes.     But  as  these  recom- 
mendations are  too  lengthy  for  transcription,  those  interested  in 
this   subject   will   find   an  excellent   notice   of   the  Committee's 
conclusions  and  advice  at  page  641  in  the  Journal  (Chicago)  of 
3rd  November  1888. 

ANTiFEBiiiN  AS  A  PoisoN. — A  case  of  poisoning  by  antifebrin 
is  published  by  Dr  C.  S.  Freund  of  Cologne  in  the  Deutsche 
Medicin.  Wochenschrift,  xiv.  p.  41,  1888.  A  man,  aged  29,  took 
6  grammes  (92  grains)  of  antifebrin  in  two  equal  doses  within 
four  hours.  Alarming  cyanosis  supervened,  extending  even  to  the 
point  of  the  nose  and  to  the  finger  nails,  and  the  pulse  became 
greatly  accelerated.  The  cyanosis  passed  off  slowly,  but  had  dis- 
appeared in  three  days.  The  blood  was  found  unaltered  both  to 
microscopic  and  to  spectroscopic  examination.     The  urine  was  not 


958  PERISCOPE.  [APRIL 

increased,  nor  was  it  characterized  by  any  special  change  in  colour, 
though  its  specific  gravity  was  diminished.  This  case,  as  the 
reporter  (in  Schmidt's  Jahrbiicher  for  January  1889,  p.  19) 
remarks,  shows  the  comparatively  non-fatal  effect  of  even  exces- 
sive doses  of  antifebrin  when  administered  in  non-febrile  cases. 
In  fever  cases,  however,  unpleasant  symptoms  are  proportionately 
much  more  frequent.  Dr  Leo  Lowenthal  in  Frankfort-on-the-Main, 
and  Dr  Kronecker  in  Berlin,  reported  in  the  September  number 
of  the  Therap.  Monatschrift,  1 888,  cases  in  which  great  depression 
followed  the  exhibition  in  pyrexia  of  even  small  doses  of  the  drug. 
Large,  however,  as  is  the  above  dose  of  6  grammes  in  four  hours, 
it  has  been  exceeded  by  Dr  Simpson  of  New  York,  who  (Philadelphia 
Medical  and  Surgical  ^Reporter,  10th  November  1888,  p.  586),  for 
the  sake  of  experiment,  took  100  grains  in  seven  single  doses 
within  two  hours  and  a  half.  In  connexion  with  this  subject,  a 
ready  method  of  determining  the  presence  of  antifebrin  in  the 
urine  is  noted  in  the  Philadelphia  Medical  and  Sttrgical  Reporter 
as  above.  This  method  depends  on  the  production  of  the  indo- 
phenol  reaction  whereby  aniline  is  formed,  antifebrin  itself  offering 
great  resistance  to  chemical  reagents.  The  detail  is : — Mix  the 
urine  to  be  examined  with  one-quarter  of  its  vohime  of  concen- 
trated sulphuric  acid,  and  boil  for  some  time.  After  cooling,  add 
one  drop  of  liquid  carbolic  acid  and  a  few  drops  of  a  solution  of 
chloride  of  lime.  If  antifebrin  be  present,  a  red  coloration 
appears,  which,  by  addition  of  ammonia,  turns  to  a  beautiful  blue. 


OCCASIONAL  PERISCOPE  OF  DERMATOLOGY. 

By  W.  Allan  Jamieson,  M.D.,  F.R.C.P.,  Extra  Physician  for  Diseases  of 
the  Skin,  Edinburgh  Royal  Infirmary ;  Lecturer  on  Diseases  of  the  Skin, 
Edinburgh  School  of  Medicine. 

Lichen  Ruber  as  observed  in  America,  and  its  distinction 
FROM  Lichen  Planus. — The  question  of  the  identity  or  non- 
identity  of  lichen  ruber  as  described  by  Hebra  and  lichen  planus  as 
observed  by  Wilson  has  often  been  raised,  and  although  Kaposi  is 
of  opinion  that  these  are  but  variants  of  the  same  disease,  this  view 
has  not  been  unreservedly  accepted.  Dr  Taylor  of  New  York 
holds  that  lichen  ruber  is  a  distinct  morbid  entity  without  a  shadow 
of  relation  to  lichen  planus.  He  has  seen  six  instances  which  he 
regards  as  lichen  ruber,  while  he  has  recorded  sixty-four  of  lichen 
planus,  so  that  his  experience  is  considerable.  He  divides  the 
course  of  lichen  ruber  into  three  stages — 1.  That  of  isolation  of  the 
papules.  When  first  seen  these  are  of  the  size  of  the  point  of  a  pin  or 
needle,  present  to  the  touch  a  sensation  of  firmness,  and  give  the 
skin  a  roughened  feel.  They  increase  to  the  size  of  a  millet  seed, 
and  look  like  conical  masses  of  yellow  wax,  of  a  neutral  orange 
colour.  At  this  period  the  disease  might  be  called  lichen  ruber 
acuminatus.     But  this  conical  condition  is  not  of  long  duration; 


1889.]  PEHISCOPE   OF  DEEMATOLOGY.  959 

they  rise  up  and  become  rounded  or  obtuse,  and  at  this  stage  the 
term  lichen  ruber  obtusus  might  be  applied.  Still  growing  they 
become  flattened,  and  in  some  a  depression  in  the  centre  of  the 
papule  may  be  noted.  When  this  limit  is  reached  the  term  lichen 
ruber  planus  is  admissible.  The  luUy  formed  papule  presents  a 
rounded  outline,  perhaps  somewhat  ovoid,  but  not  angular  or  poly- 
gonal, though  very  uniform  in  size.  Minute,  thin,  more  or  less 
adherent  scales  are  seen  on  them,  and  they  desquamate  slightly. 
They  may  vary  in  time  from  dark  yellow  to  brownish  red,  but  not 
violaceous  or  crimson  red.  The  extension  of  the  disease  is  pro- 
gressive, and  the  papules  become  so  closely  set  as  possibly  to  cover 
the  whole  surface :  this  forms — 2.  The  stage  of  coalescence  of  the 
papules.  From  maturity  of  growth  and  multiplication  in  numbers 
the  papules  become  first  crowded  together,  and  fiinaliy  fused  into  a 
patch  more  or  less  extensive.  The  final  condition  is  that  of  a 
uniform  brownish-red,  slightly  scaly,  superficial  thickening  of  the 
skin,  imparting  a  miniature  resemblance  to  an  alligator's  hide.  This 
constitutes  the  third  stage,  in  which  the  disease  is  chronic,  indolent, 
infiltrated,  scaly,  and  slightly  pigmented,  all  signs  of  previous  papula- 
tion having  disappeared,  and  no  new  lesions  then  showing  them- 
selves, though  involution  may  occur  after  considerable  periods,  and 
as  this  occurs  the  suppleness  and  natural  glossiness  of  the  surface 
returns,  mild  pigmentation  persisting,  accompanied  by  moderate 
desquamation.  There  may  be  appearances  in  the  palms  and  soles, — 
in  the  former  situation  resembling  chronic,  scaly,  and  infiltrated 
eczema,  in  the  latter  marked  epidermic  thickening.  The  nails,  too, 
may  become  rough,  yellow,  and  very  much  thickened.  The  micro- 
scopic appearances  are  detailed  and  very  fully  illustrated,  as  are 
also  the  clinical  features.  Dr  Taylor  concludes  that  there  is  in 
lichen  ruber  an  hypertrophy  of  all  the  layers  of  the  epidermis, 
associated  with  an  exudative  inflammation  in  the  papillae  and 
papillary  derma.  In  treatment  he  does  not  regard  arsenic  as  a 
specific.  Alkaline  diuretics  seem  to  have  done  good  in  one  of  his 
cases,  while  a  combination  of  citrate  of  iron,  quinine,  phosphoric 
acid,  and  strychnia  benefited  the  other.  Alkaline  baths  he  regards 
as  of  much  value,  combined  in  some  cases  with  frictions  with  the 
compound  tincture  of  green  soap.  For  the  thickened  condition  of 
the  hands  and  feet  freshly  made  diachylon  ointment  with  a  draclim 
of  balsam  of  Peru  in  each  ounce,  kept  applied,  gave  most  relief. — 
New  York  Medical  Journal,  Jan.  5th,  1889. 

Accidents  which  may  follow  the  Suppression  of  a  Chronic 
EczEMATOUS  Eruption. — Partly  from  fear  of  inducing  visceral 
complications  as  a  result  of  their  too  rapid  disappearance,  partly 
from  an  inability  to  cope  with  them  successfully,  medical  men  used 
to  respect  eczematous  lesions,  and  allow  them  to  run  on  as  they 
would.  At  present  the  prevailing  opinion  is  that  no  harm  can 
accrue  to  the  patient  from  curing  an  eczema.     Dr  Brocq,  while 


960  PEKISCOPE.  [APltIL 

agreeing  tliat  this  applies  to  the  large  majority  of  cases,  believes 
that  there  are  circumstances  in  which  the  old  ideas  are  correct. 
Dr  Besnier  has  remarked  that  when  treating  old  eczemas  of  the  legs 
it  is  necessary  to  watch  the  urine,  while  in  treating  those  of  the 
trunk  it  is  necessary  to  watch  the  cliest,  since  inflammatory  out- 
bursts might  occur  in  these  cases  either  in  tiie  kidneys  or  the 
lungs.  It  is  specially  important  to  attend  to  this  when  treating 
emphysematous  asthmatics  who  suffer  from  chronic  eczema.  In 
such  the  greatest  prudence  must  be  exercised ;  we  must  wait  till 
the  pulmonary  organs  are  in  the  most  perfect  state  before  instituting 
any  efficacious  local  treatment  for  the  eczema,  and  suspending  this 
at  once  as  soon  as  one  sees  any  signs  of  congestive  outbreaks  in  the 
lungs.  Dr  Brocq  relates  some  valuable  cases  which  fully  illustrate 
these  remarks.  Those  must  be  studied  in  the  paper  itself,  which 
is  one  of  more  than  ordinary  interest  and  value.  It  is  by  no  means 
meant  that  we  are  not  to  treat  chronic  eczema,  it  is  the  mode  to 
adopt  in  so  doing  which  needs  attention.  "  If  we  have  to  deal  with 
a  chronic  eczema  having  very  little  intensity,  and  causing  but  little 
trouble,  and  the  appearance  of  which  on  the  podex,  or  the  lower 
limbs,  or  the  articular  folds,  has  coincided  with  the  disappearance 
of  some  neuralgia,  or  migraine,  or  an  attack  of  asthma,  or  of 
bronchitis,  etc.,  so  long  as  the  eczema  remains  limited  and  does  not 
inflame,  nor  ooze  too  much,  and  does  not  cause  intolerable  itching, 
it  would  be  probably  prudent  to  watch  it,  to  soothe  it  from  time  to 
time,  but  not  to  force  its  disappearance.  This  is  a  piece  of  advice 
which  we  would  give  especially  where  the  disappearance  of 
this  eczema  has  already  been  accompanied  by  grave  disturbance  in 
connexion  with  the  viscera."  When  such  morbid  phenomena  are 
developed  after  the  disappearance  of  a  dermatosis,  our  prognosis 
should  not  be  too  gloomy.  In  such  cases  we  should  act  as  energeti- 
cally as  possible  by  means  of  revulsives ;  and  should  under  their 
influence  the  dermatosis  return,  and  the  internal  troubles  simul- 
taneously vanish,  our  line  of  treatment  should  in  the  future  be 
cautious.  In  some  of  the  cases  cited  by  Dr  Brocq  a  course  of 
treatment  at  Bourboule  appeared  to  be  of  much  value  in  bringing 
about  a  satisfactory  issue.  Is  it  possible  that  the  mere  ingestion  of 
considerable  or  large  amounts  of  water,  mildly  alkaline,  for  those 
unable  to  undertake  such  a  journey,  might  prove  nearly  as 
efficacious  ? — The  British  Journal  of  Dermatology ^  No.  4,  1889. 

Anthrakobin. — Dr  Bronson  confirms  the  value  of  this  remedy 
in  the  treatment  of  psoriasis.  He  employed  a  ten  per  cent,  ointment 
in  vaseline  applied  once  a  day.  For  a  time  an  alkaline  bath  was 
given  before  using  the  ointment ;  but  as  this,  while  it  undoubtedly 
rendered  the  anthrarobin  more  active,  increased  the  deep  purple 
discoloration  of  the  skin,  it  was  omitted.  Any  irritation  produced 
by  the  ten  per  cent,  preparation  was  scarcely  appreciable.  When, 
however,  in  one  case  a  twenty  per  cent,  ointment  was  employed,  it 


1889.]  PERISCOPE   OF   DERMATOLOGY.  961 

occasioned  a  difFase  dermatitis  in  course  of  a  week,  differing  in  no 
respect  from  that  evoked  by  chrysarobin.  When  chrysarobin  is 
used  in  psoriasis  it  is  often  noted  that  the  most  striking  change  in 
the  progress  of  the  cure  corresponds  with  the  development  of  a 
dermatitis,  which  seems  associated  with  an  inhibitory  action,  both 
on  the  cellular  hyperplasia  and  on  the  hypercemia  of  the  psoriatic 
patch.  Whether  inflammation  of  the  surrounding  skin  is  a 
necessary  condition  of  this  inhibitory  action,  or  M'hether  the  same 
thing  is  effected  by  anthrarobin  without  inflammation,  is  a  question, 
but  certain  it  is  that  all  signs  of  the  disease  are  made  to  disappear  by 
this  agent  as  completely,  if  not  as  speedily  also,  as  by  chrysarobin. 
— Journal  of  Cutaneous  and  Genito-  Urinary  Disease,  Nov.  1888. 

Whitlow. — Chambard  has  examined  with  suitable  precautiona 
the  pus  from  a  subcutaneous,  the  serum  from  a  subepidermic  whitlow, 
in  several  cases,  and  has  found  not  only  a  streptococcus  and  a 
staphylococcus  but  other  forms  of  micrococci.  He  has  found  the 
following  mode  of  treatment  the  most  speedy  and  effectual.  If 
subcutaneous,  after  opening  it  and  purifying  the  cavity  by  injections 
of  solution  of  carbonic  acid,  this  is  packed  with  iodoform  ;  if  sub- 
epidermic,  the  roof  having  been  cut  away  the  exposed  surface  is 
similarly  treated  ;  a  piece  of  iodoform  gauze  and  a  bandage  complete 
the  dressings,  which  are  daily  renewed. — Annales  de  dermatologie 
et  de  syphiligra^phie,  No.  7,  1888. 


PEKISCOPE  OF  OPHTHALMOLOGY. 
By  George  A.  Beery,  M.B. 

An  Operation  extensively  employed  in  Russia  for  Entropion 
AND  Trichiasis. — A  description  of  an  operation,  which  is  practically 
a  combination  of  the  methods  of  Snellen  and  Hotz,  is  given  by 
Germann  in  the  second  part  of  the  St  Petersburg  Ophthalmic 
Hospital  Reports.  The  operation  was  first  introduced  into  Russia 
by  Dohnberg  in  1880,  and  soon  superseded  there  all  the  other 
methods  of  operating  for  entropia.  It  was  not,  however,  until  1884 
that  Dohnberg  published  an  account  of  his  operation  in  the  Vestnik 
Opiitalmologii.  Though  very  extensively  performed  in  Russia, 
where  the  number  of  cases  requiring  an  operation  of  this  kind  is 
relatively  enormous,  it  appears  not  to  be  known  in  the  other 
countries  of  Europe,  or,  at  all  events,  is  not,  according  to  Germann, 
referred  to  in  any  of  the  numerous  text-books  which  have  lately 
appeared.  The  first  step  in  the  operation  consists,  after  the  intro- 
duction of  Snellen's  entropion  forceps,  in  making  an  incision 
extending  through  skin  and  muscle  down  to  the  tarsus  parallel  to 
the  lid  margin  and  about  3  mm.  above  it.  A  second  incision  is 
then  made  parallel  to  the  first,  and,  on  an  average,  about  7  mm. 
higher  up.  The  intervening  skin  and  muscle  are  then  removed 
with  forceps  and  scissors.  The  extent  of  skin  to  be  removed  will 
depend  upon  whether  it  is  or  is  not  copious ;  when  it  is  very  lax  a 

EDINBURGH   MED.    JOURN.,    VOL.    XXXIV. — NO.   X.  6   F 


902  PERISCOPE.  [apkil 

broader  strip  tlian  7  mm.  may  be  excised ;  when,  on  the  other 
hand,  it  is  exceedingly  scanty,  the  tissues  should  merely  be  dis- 
sected up  off  the  tarsus  from  the  first  incision.  After  this  has  been 
done,  the  second  step  consists  in  the  removal,  in  the  ordinary  way, 
of  a  wedge-shaped  portion  of  the  tarsus,  the  base  of  which  should 
average  about  3  mm.  in  breadth.  As  a  third  and  final  step  the 
stitches  are  introduced  in  the  following  manner : — They  are  entered 
immediately  above  the  cilia,  passed  along  over  the  tarsus,  then 
through  its  fascia  above,  and  finally  through  the  skin  above. 
Three  or  four  of  these  sutures  are  used,  the  central  one  being 
always  first  tied.  Germann  has  modified  the  method  of  applying 
these  sutures  in  a  way  which  he  considers  presents  some  advan- 
tages. He  does  not  pass  them  through  the  skin  above,  but  after 
having  got  a  firm  hold  of  the  tarsal  fascia,  he  brings  the  thread 
back  again  over  the  tarsus  and  out  at  3  to  4  mm.  distance  from  its 
point  of  entry.  He  uses  three  sutures,  and  in  tying  them  takes 
care  that  the  approximation  of  the  two  portions  of  the  tarsus  is 
complete.  He  then  introduces  superficial  stitches  for  the  skin.  By 
this  proceeding,  too,  it  is  easy  to  increase  the  effect,  siiould  it  be 
desirable  after  the  deep  stitclies  have  been  tied,  by  cutting  away  a 
little  more  skin.  Like  most  operations  of  the  kind,  that  just 
described  appears  to  encounter  the  difficulty  of  not  producing 
always  sufficient  effect  at  the  outer  and  inner  angles.  In  bad  cases, 
therefore,  it  is  preceded  by  canthoplasty,  and  after  the  rest  of  the 
operation  has  been  finished,  the  lower  incision  is  prolonged  to 
either  side  with  a  pair  of  straight  scissors,  and  with  the  aid  of  these 
and  a  pair  of  forceps  two  further  pieces  of  skin  and  muscle  of  tri- 
angular shape  on  the  bases  thus  marked  out  are  excised  and 
brought  together  by  deep  sutures.  The  operation  is  almost  invari- 
ably performed  at  St  Petersburg  without  an  anaesthetic.  Finns, 
amongst  whom  trichiasis  is  a  very  common  affection,  appear  to  bear 
pain  remarkably  well.  The  dressing  consists  of  iodoform  next  the 
wound,  over  this  a  piece  of  cotton-wool  dipped  in  corrosive  sub- 
limate solution  (1  to  3000),  then  a  piece  of  gutta-percha  tissue 
covered  by  some  dry  cotton-wool.  A  flannel  bandage  is  then 
applied  to  keep  the  dressing  in  position.  It  is  not  removed  for  two 
or  three  days,  and  then  not  reapplied.  Patients  treated  in  the 
hospital  remain  five  or  six  days.  Many  are  treated  as  out-patients. 
From  1880  to  1887  the  Snellen-Hotz  operation  was  performed 
1545  times.  Experience  has  shown  that  recurrence  is  less  frequent 
after  this  than  after  other  operations  performed  in  the  same  hospital 
for  the  cure  of  entropion.  It  is  not  easy  to  get  at  the  exact  propor- 
tion of  recurrences  owing  to  the  great  distances  at  which  many  of 
the  patients  operated  on  live.  Germann's  own  experience  gives 
between  3  and  4  per  cent. 

V.    Hippel's    Method    op    Transplanting    Cornea. — The 
transplantation  of  clear  corneal  tissue  to  take  the  place  of  the  opaque 


1889.]  PERISCOPE   OF   OPHTHALMOLOGY.  963 

cicatrix  which  is  left  after  ulceration  has  been  repeatedly  tried.  So 
far  tlie  method  of  doing  this,  introduced  by  v.  Hippel  a  few  years 
ago,  appears  to  have  been  the  only  one  followed  by  anything  like 
permanent  success.  After  having  given  the  operation  a  more 
extensive  trial,  v.  Hippel  has  recently  {Graefe's  Archiv,  xxxiv.) 
published  a  very  full  account  of  it,  and  has  pointed  out  the  precau- 
tions which  seem  necessary  at  each  step.  Of  eight  cases  operated 
on,  four  were  considered  to  have  been  successful.  From  a  degree 
of  visual  acuity  not  amounting  to  more  than  an  ability  to  count 
figures  at  6  or  9  feet,  the  patients  attained  after  operation  200 "  The 
operation  itself  is  altogether  free  from  danger,  and  may  be  under- 
taken in  any  case  where  there  is  not  extensive  attachment  of  the  iris 
to  the  back  of  the  leucoma,  or  considerable  alteration  in  corneal 
curvature.  A  portion,  generally  about  4  mm.  in  diameter,  is 
removed  from  the  patient's  opaque  cornea  by  means  of  a  trephine, 
which  is  guarded  by  a  ledge  to  prevent  its  entering  too  deeply,  and 
the  cutting  edge  of  which  is  set  in  rotation  by  means  of  clockwork, 
in  order  to  render  it  possible  to  obtain  great  precision  in  the  depth 
and  perpendicularity  of  the  incision  all  round.  The  result  of  Leber's 
experiments  in  connexion  with  the  flow  of  fluids  within  the  eye,  as 
well  as  the  failure  of  previous  attempts  at  transplantation,  led 
v.  Hippel  to  recognise  that  an  essential  condition  of  success  consists 
in  leaving  Descemet's  membrane  intact.  Only  by  doing  so  can  the 
transparency  of  the  transplanted  portion  be  permanently  maintained. 
In  removing  the  portion  circumscribed  by  the  trephine  with  a  pair 
of  fine  scissors  and  Graefe's  kt)ife,  care  must  therefore  be  taken  not 
to  perforate,  while  at  the  same  time  as  level  a  floor  as  possible  is 
desirable.  The  next  step  consists  in  the  removal  of  a  portion  of 
a  rabbit's  cornea.  This  is  done  with  the  same  trephine,  and  must 
involve  the  whole  thickness  of  the  cornea.  The  ditficulty  in  this 
step  appears  to  be  to  keep  the  rabbit  sufficiently  quiet,  although  its 
cornea  is  well  cocainized  to  permit  of  the  excised  portion  having 
exactly  the  desired  shape.  When  the  portion  of  rabbit's  cornea  has 
been  obtained  it  is  glided  into  position,  and  care  taken  that  it 
comes  to  lie,  as  far  as  possible,  flush  with  the  rest  of  the  corneal 
surface,  otherwise  it  is  readily  displaced.  Iodoform  is  then  powdered 
on  the  eye,  and  both  eyes  are  bandaged  and  not  touched  for  two  or 
three  days,  after  which  a  daily  dressing  is  applied.  No  vascularity 
or  intransparency  of  the  graft  occurs  where  it  succeeds. 

A  Case  of  Spontaneous  Hematoma  of  the  Orbit,  with  a 
NEW  Clinical  Fact  suggestive  of  the  Cause. — Spontaneous 
hasmorrhage  into  the  orbit  is  of  very  rare  occurrence.  Prof  Panas 
of  Paris  has  recently  had  such  a  case  under  treatment,  an  account 
of  which  is  published  in  the  A7xhives  d' Oi^htalmologie,  vol.  viii. 
The  following  are  the  main  points  of  the  case  : — Protrusion  of  left 
eye  in  a  boy  of  4;  previously  good  health,  with  exception  of 
repeated  epistaxis ;  parents  healthy.     A  fortnight  previously  lids 


964  PERISCOPE.  [APRIL 

found  one  morning  to  be  swollen,  bat  not  discoloured ;  same  day 
repeated  vomiting  and  epistaxis.  Examination  : — When  first  seen 
by  Panas  there  was  great  protrusion,  with  slight  displacement 
inwards ;  pupil  dilated  and  motionless ;  lids  swollen,  but  not  dis- 
coloured. Nothing  was  felt  on  deep  palpation  except  a  hard  mass 
upwards  and  outwards,  no  doubt  the  lacrymal  fluid  pushed  forwards 
out  of  its  place.  Ophtlialmoscopically : — Papilla  white ;  veins 
swollen  and  tortuous,  arteries  narrowed ;  no  perception  of  light. 
Pressure  did  not  reduce  the  exophthalmus  ;  fluctuation  readily  made 
out.  On  making  a  deep  incision  escape  of  black  liquid  blood. 
The  case  was  afterwards  dressed  antiseptically  and  drained.  Slight 
improvement  first  day ;  afterwards  recurrence  of  protrusion,  though 
to  less  extent.  After  six  weeks,  recovery,  with  complete  loss  of 
sight.  Repeated  examinations  were  made,  with  the  object  of  dis- 
covering whether  any  abnormal  condition  of  the  heart,  bloodvessels, 
liver,  spleen,  kidneys,  or  lymphatic  glands  existed  which  might 
account  for  the  hasmorrhage,  but  always  with  a  negative  result. 
The  attacks  of  indigestion  and  vomiting,  from  which  the  child 
suffered,  showed  him  to  be  dyspeptic.  The  abdomen  was  prominent 
and  tympanitic.  The  frequent  epistaxis  always  coincided  with 
attacks  of  indigestion,  sometimes  going  on  to  vomiting.  Panas's 
conclusion  is  that  the  orbital  hsematoma  was,  thougii  an  excep- 
tionally rare  occurrence,  of  exactly  the  same  nature  as  the  epistaxis, 
and  connected  with  the  dilatation  of  the  stomach. 

Amblyopia  in  Nitro-benzol  Poisoning. — Dr  Nieden  of  Bochum 
has  had  opportunities  of  studying  the  symptoms  of  poisoning  met 
with  amongst  the  workers  in  the  only  manufactory  of  the  new 
explosive  rohorite,  which  is  situated  at  Witten,  not  far  from  Bochum. 
The  poisonous  element  in  this  explosive,  which,  though  more  power- 
ful than  any  other  explosive,  is  apparently  much  safer,  is  nitro- 
benzol.  In  less  than  a  year  twenty-five  out  of  the  thirty  work- 
men were  more  or  less  dangerously  poisoned.  This  was  mainly,  no 
doubt,  due  to  their  neglecting  the  prescribed  precautions  for  avoiding 
the  inhalation  of  the  fumes  which  arise  during  the  process  of  manufac- 
ture. All  the  cases  recovered  completely.  The  symptoms  observed 
were  evidently  due  to  vaso-motor  paralysis  in  the  heart  and  blood- 
vessels, and  consequent  overfilling  of  the  veins.  In  only  one  case 
did  this  condition  affect  the  eyes.  Vision  was  reduced  to  ^;  there 
was  great  concentric  restriction  of  the  fields  of  vision,  but  not  a 
corresponding  restriction  for  colours,  the  boundaries  for  which  came 
pretty  close  up  to  those  for  white.  Ophthalmoscopically  there  was 
marked  venous  hyperasmia  of  the  retina,  and  a  distinctly  circum- 
scribed exudation  surrounding  the  principal  descending  vein.  The 
general  condition  of  the  patient  improved  rapidly  under  the  use  of 
digitalis  and  other  cardiac  tonics,  but  the  vision  remained  much 
the  same  for  four  weeks,  after  which  it  was  slowly  regained,  and 
the  ophthalmoscopic  changes  disappeared. — CentralUatt  f.  Auqenh., 
July  1888. 


1889.]  SUKGICAL  PERISCOPE.  965 

SURGICAL  PERISCOPE. 
By  A.  G.  Miller,  F.R.CS.E. 

A  Question  regarding  Tracheotomy  {Brooklyn  Medical 
Journal,  1888). — The  Brooklyn  Surgical  Society  discussed  the 
subject  of  tracheotomy  on  the  5th  January  1888,  The  discussion 
was  opened  by  a  paper  by  Dr  A.  Lewis,  who  maintained  that  the 
operation,  in  cases  of  children  suffering  from  "  the  diseases  named 
croup  and  diphtheria,"  should  never  be  urged  on  the  parents,  nor 
even  recommended.  He  repeatedly  stated  that  he  would  operate 
only  when  requested  by  the  parents.  He  takes  up  this  position  on 
account  of  the  extreme  fatality  of  the  operation  and  the  shock  that 
it  may  be  to  an  already  enfeebled  and  exhausted  child.  Dr 
Pilcher,  who  followed,  and  disputed  Dr  Lewis's  opinions,  said  that, 
seeing  the  danger  to  life  is  largely  from  air  not  entering  the  lungs, 
relief  to  the  respiration  must  always  be  beneficial,  and  it  is  the  duty 
of  the  surgeon  to  advise  and  not  to  wait  till  he  is  requested  to 
operate.  To  use  his  own  words, — "  It  does  seem  to  me  in  such 
cases  we  are  not  doing  our  duty  if  we  do  not  have  some  definite 
advice  to  give."  He  considers  that  the  average  of  recoveries,  about 
25  per  cent,  in  published  cases  is  fair,  and  what  ought  to  be  ex- 
pected. He  considers  that  the  number  of  cases  in  which  an  opera- 
tion is  refused  by  the  parents  and  the  children  recover  is  not  so 
large  as  is  supposed,  from  the  cases  being  often  repeated  and  made 
much  of.  Dr  Lewis  had  said  that  he  had  often  regretted  that  he 
had  operated  in  cases  that  had  ended  fatally.  He,  Dr  Pilcher,  on 
the  other  hand,  had  often  been  glad  that  he  had  operated,  even  though 
the  little  patients  had  died,  because  their  lives  had  been  prolonged 
and  their  deaths  had  been  more  peaceful.  Dr  Rockwell,  in  continu- 
ing the  discussion,  said  that  the  surroundings  of  the  child,  and  the 
possibilities,  or  the  opposite,  of  carrying  out  the  after-treatment 
properly,  would  very  materially  influence  him  in  recommending 
the  operation  in  any  given  case.  Dr  Fowler  complained  of  the 
manner  in  which  medical  attendants  often  put  off  calling  in  the 
surgeon  till  the  child  is  in  extremis.  He  would  recommend  the 
operation  strongly.  "  If  it  was  my  child,  I  should  have  the  trachea 
opened,  and  1  should  not  wait  until  it  was  in  extremis;  I  would  do 
it  early."  He  considered  that  the  success  of  the  operation  depended 
mostly  on  the  after-treatment.  Drs  Wackerhagen,  "Wight,  and 
Wunderlich  spoke  in  favour  of  operating,  because  it  might  save  life 
and  alleviate  suffering.  Dr  Bogart  spoke  in  favour  of  intubation.  In 
concluding  the  debate,  Dr  Lewis,  replying,  said  that  there  was  not 
much  difference  of  opinion  between  himself  and  the  other  speakers, 
except  that  he  was  more  conservative,  and  "  more  determined  that 
the  operation  shall  be  hy  request,  if  you  please.''^  The  result  of  the 
discussion,  however,  was  very  evidently  against  Dr  Lewis,  and 
some  speakers  indignantly  objected  to  his  position  of  refusing  to 
give  advice  in  circumstances  where  the  surgeon  is  called  in  specially 
to  advise. 


966  periscope.  [april 

Results  of  Laparotomy  for  Acute  Obstruction  (B. 
Farquhar  Curtis,  M.D.,  New  York,  Annals  of  Surgery). — In  this 
paper  Dr  Curtis  gives  four  tables,  arranged  from  upwards  of 
three  hundred  recorded  cases  which  he  lias  collected.  The  first 
table  shows  the  rate  of  mortality  according  to  the  cause  of"  obstruc- 
tion. Table  two  shows  the  number  of  deaths  arranged  according 
to  the  number  of  days  that  the  obstruction  had  lasted  before 
operation.  The  third  table  shows  the  causes  of  death,  and  the 
fourth  the  operative  procedure  adopted  in  each  case.  In  con- 
clusion, he  says,  "  The  analysis  just  made  shows  a  very  high  rate  of 
mortality  for  laparotomy,  but  this  is  due  chiefly  to  the  bad 
condition  of  the  patients  at  the  time,  the  operation  having  been 
too  long  delayed.  By  operating  earlier,  we  shall  not  only  have 
the  patient  in  better  condition,  but  we  shall  avoid  the  dangers  of 
peritonitis  and  gangrene  of  the  gut,  and  the  difficulties  caused  by 
excessive  tympanitis.  A  short,  simple  operation  gives  almost  the 
only  hope  of  success,  and  the  earlier  the  operation  is  performed  the 
shorter  and  simpler  it  may  be  made." 

CESOPHAGOTOMY     FOR     UeMOVAL     OF     FoREIGN     BODY     (J.     S. 

M'Ardle,  F.R.C.S.,  Dublin  Journal  of  Medical  Science).  —  The 
foreign  body  was  impacted  on  the  left  side,  just  above  the 
sternum.  It  had  been  in  this  situation  for  about  a  month,  and  had. 
caused  a  considerable  amount  of  irritation  and  inflammation.  A 
swelling,  about  the  size  of  "  a  small  egg,"  lay  behind  the  sternal 
attachment  of  the  left  sterno-mastoid.  Pressure  on  the  swelling 
caused  sharp  pain.  Mr  M'Ardle  considered  that  the  foreign  body, 
a  piece  of  beef  bone,  had  penetrated  the  wall  of  the  oesophagus  on 
the  left  side,  and  was  probably  pressing  on  the  vessels.  There 
were  no  symptoms  of  nerve  pressure  or  irritation.  Mr  M'Ardle 
determined  to  cut  down  on  the  foreign  body  and  remove  it,  so  as 
to  prevent  perforation.  An  incision  made  along  the  anterior 
border  of  the  sterno-mastoid  at  the  lower  part  revealed  adhesion  of 
the  oesophagus  to  the  vessels.  Lest  any  injury  should  happen  to  the 
carotid,  two  provisional  ligatures  were  passed  round  the  vessel  above 
and  below  the  adherent  area.  To  enable  him  to  do  this,  Mr  M'Ardle 
cut  through  and  reflected  the  sternal  attachments  of  the  sterno- 
mastoid,  sternohyoid,  and  sterno-thyroid.  The  thickened  oeso- 
phagus was  then  incised,  and  two  pieces  of  bone  discovered  and 
removed.  They  were  both  imbedded  in  the  wall  of  the  oesophagus 
(size  not  mentioned).  The  wound  was  washed  with  carbolic  lotion, 
and  plugged  with  iodoform  gauze.  The  patient  made  a  good 
recovery.  In  remarking  on  the  after  treatment  of  the  case,  Mr 
M'Ardle  said  that  he  put  great  faith  in  the  antiseptic  plugging  of 
such  a  wound,  to  prevent  septic  infiltration  of  the  cellular  tissue  of 
the  neck.  The  provisional  ligatures  on  the  carotid  were  not 
required. 

Pott's   Fracture    and    Talipes   Equino-varus    (T.    Bland 


1889.]  SUEGICAL  PERISCOPE.  967 

Sutton,  F.E-.CS.,  American  Journal  of  Medical  Sciences). — This 
very  characteristic  article  deals  first  with  Pott's  fracture  of  the 
fibula,  and  shows,  from  comparison,  or  rather  contrast  with  the 
quadrumana,  how  the  fracture  occurs  in  man  and  is  possible  in 
man  alone.  When  the  foot  is  forcibly  everted  the  length  of  the 
external  malleolus  supplies  a  leverage  by  which  the  fibula  is  broken 
at  the  ordinary  point,  viz.,  1\  in.  above  the  inferior  tibio-fibular 
articulation.  Mr  Sutton  says, — "Pott's  fracture  is  peculiar  to  the 
human  kind,  and  occurs  as  a  direct  result  of  the  extraordinary 
length  of  the  fibular  malleolus,  in  that  it  affords  excessive  leverage 
when  the  foot  is  suddenly  and  violently  twisted  laterally"  (out- 
wards). In  regard  to  congenital  talipes,  Mr  Sutton  points  out  that 
at  the  seventh  month  of  intrauterine  life  the  two  malleoli  are  on 
the  same  level,  and  tiie  foot  in  the  position  of  varus.  This  goes  to 
prove  that  congenital  talipes  (equino-varus)  is  due  to  an  arrest  of 
the  development  or  evolution  of  the  foot  at  that  period.  In  quad- 
rumana the  malleoli  are  of  the  same  length,  and  in  consequence 
their  gait  in  walking  is  uncertain  and  "wobbling."  These  facts  are 
of  great  interest  to  the  evolutionist.  At  the  same  time  Mr  Sutton 
points  out,  that,  while  "  in  the  greater  length  of  the  adult  fibular 
malleolus  we  have  a  condition  absolutely  human,  and  possibly  one 

of  the  direct  results  of  the  assumption  of  the  erect  position, 

it  is  quite  as  probable  that  an  elongation  of  the  fibular  malleolus 
may  have  played  a  part  in  enabling  man  to  assume  and  maintain 
an  erect  position." 

Carcinoma  of  the  Breast  and  its  Treatment  (Samuel  W. 
Gross,  M.D.,  LL.D.,  etc.,  Philadelphia,  American  Journal  of 
Medical  Sciences). — Second  Notice. — Prof.  Gross  commences  with 
an  elaborate  analysis  of  1527  cases.  The  result  is  stated 
under  five  heads : — 1.  Carcinoma  left  to  itself  inevitably  kills. 
2.  About  one  in  seven  die  from  the  operation.  (This  is  a 
high  proportion  with  many  surgeons,  especially  since  the  introduc- 
tion of  antiseptics).  3.  Operations  of  all  kinds  cure  about  12  per 
cent.  4.  Patient  is  safe  from  reproduction  if  three  years  have 
elapsed  since  the  operation.  5.  Recurrence  may  be  delayed  for 
several  months,  or  altogether  prevented,  by  clearing  out  the  axilla. 
(A  recent  writer,  Mr  Butlin,  combats  this  last  statement,  and  con- 
tends that  it  is  not  necessary  to  remove  the  glands  in  every  case, 
even  when  they  are  enlarged.  On  the  other  hand,  it  must  be 
remembered  that  the  disease  sometimes  recurs,  not  in  the  glands, 
but  in  cicatrix,  or  at  some  other  point  of  irritation,  such  as  a  suture 
aperture.)  Prof.  Gross  then  takes  up  the  subject  of  diagnosis, 
which  should  be  "based  upon  the  age  of  the  patient,  the  average 
being  48  yeai-s,  the  dimpling  of  the  skin,  the  retraction  of  the 
nipple,  the  immobility  of  the  solitary  tumour  of  the  mamma,  or  if 
it  be  seated  at  the  periphery,  its  intimate  attachment,  its  nodular 
outline,  its  small  size,  its  slow  growth,  and  its  stony  hardness." 


968  PERISCOPE.  [APRIL 

(It  seems  to  be  a  pity  that  the  diagnosis  of  scirrhus  before  some  of 
these  symptoms  are  evident  is  not  dwelt  upon.  For  all  are  agreed 
that  the  sooner  a  malignant  tumour  is  removed  the  better  for  the 
patient;  and  the  dimpling  of  the  skin  and  retraction  of  the  nipple 
indicate  that  some  progress  has  been  made  towards  involvement  of 
surrounding  textures.)  Prof  Gross  next  refers  to  treatment.  His 
views  on  this  point  are  well  known.  They  may  be  summed  up  as 
early  toidi  free  removal  of  the  whole  mamma,  and  also  all  the  skin 
covering  the  gland,  along  with  the  whole  contents  of  the  axilla. 
After  stating  this  as  his  method  of  procedure,  and  urging  it  on  all 
surgeons  very  strongly,  he  says,  near  the  end  of  the  paper,  that 
having  found  other  surgeons'  success  "  nearly  as  good  as  my  own," 
he  has  so  far  modified  his  operation  as  to  leave  "  sufficient  skin  to 
admit  of  bringing  the  wound  nicely  together  without  tension." 
Those  who  believe  in  the  irritation  origin  of  cancer  will  gladly  coin- 
cide with  this  statement.  Some  of  Prof  Gross's  remarks  are  worth 
reproduction.  We  will  give  two : — "  The  day  has  passed  for  the 
physician  to  declare  that  a  tumour  was  not  a  cancer  because  it  did 
not  recur  after  removal."  "  The  sooner  women  learn  that  the  dis- 
ease can  be  cured  by  early  and  adequate  operation,  the  better  it  will 
be  for  their  sex,  and  the  greater  will  be  the  credit  accruing  to  our 
art."  He  might  have  added  that  the  sooner  family  physicians 
learn  that  in  doubtful  cases  a  competent  surgeon  should  be  con- 
sulted, the  better  for  all  concerned ;  for  a  not  uncommon  statement 
from  a  patient  is,  "  I  showed  the  lump  to  the  doctor  some  time  ago, 
and  he  said  to  wait  and  come  back  again,  as  he  was  not  quite  sure 
what  it  was." 


iiatt  dFtft!), 


MEDICAL    NEWS. 

Royal  College  of  Physicians,  Edinburgh. — The  following  gentlemen  passed 
their  final  examination  for  the  degree  in  Medicine  at  the  sittings  held  on  7th 
March  1889,  and  were  admitted  L.R.C.P.  Ed,  : — Edward  France,  SheflSeld;  Ernest 
Atherden  Thompson,  Kirkham,  Lancashire. 

Hall  of  the  College  of  Physicians. — Philadelphia,  February 
19,  1889. — The  first  triennial  prize  of  two  hundred  and  fifty 
dollars  under  the  deed  of  trust  of  Mrs  Wm.  F.  Jenks,  has  been 
awarded  by  the  Prize  Committee  of  the  College  of  Physicians  of 
Philadelphia  to  John  Strahan,  M.D.,  M.Ch.,  M.A.O.  (Royal 
University, Ireland),  247  North  Queen  Street,  Belfast,  Ireland,  for  the 
best  essay  on  "  The  Diagnosis  and  Treatment  of  Extra-Uterine 
Pregnancy."  The  writers  of  the  unsuccessful  essays  can  have  them 
returned  to  any  address  they  may  name,  by  sending  it  and  the 
motto  which  distinguished  the  essay  to  the  Chairman  of  the  Prize 
Committee,  Ellwood  Wilson,  M.D.,  College  of  Physicians,  Phila- 


1889.]  MEDICAL   NEWS. — OBITUAEY.  969 

delphia.  The  Trustees  have  made  arrangements  with  Messrs  P. 
Blakiston,  Son,  &  Co.,  1012  Walnut  Street,  Philadelphia,  for  the 
publication  of  the  successful  essay,  which  will  also  appear  in  the 
Transactions  of  the  College  for  1890. — James  H.  Hutchinson, 
John  Ashhurst,  Jr.,  James  V.  Ingham,  Trustees  of  the  Wm,  F. 
Jcnks  Prize  Fund. 


OBITUAEY. 


DEPUTY   SURGEON-GENERAL   MATTHEW  COMBE,  M.D. 

The  handsome  face  and  stalwart  figure  of  this  distinguished 
officer  were  very  familiar  to  many  of  the  senior  members  of  the 
profession  in  Edinburgh.  His  father,  the  late  Dr  Combe,  who 
graduated  on  the  day  when  the  news  of  the  battle  of  Waterloo  was 
greeted  by  the  ringing  of  the  church  bells  of  Edinburgh,  practised 
for  sixty  years  at  least  with  much  credit  and  success. 

His  son  Matthew,  after  a  distinguished  college  course,  entered  the 
service  as  Assistant  Surgeon  in  1846 ;  served  with  the  Royal 
Artillery  in  the  Crimean  Campaign  of  1854-5 ;  was  present  at  the 
battle  of  Alma,  Balaclava,  and  Inkerman,  and  at  the  siege  and  fall 
of  Sebastopol.  He  retired  from  the  service  with  the  honorary  rank 
of  Deputy  Surgeon-General  in  1876.  His  visits  to  Edinburgh 
have  been  less  frequent  since  the  death  of  his  father  and  of  his 
brother-in-law,  the  late  Dr  James  Simson,  and  of  late  years  his 
health  had  been  much  impaired. 


THE  LATE  DR  A.  J.  SINCLAIR. 

It  is  with  the  greatest  regret  we  have  to  record  the  death  of 
Dr  A.  J.  Sinclair  at  the  early  age  of  41,  which  took  place  at  his 
residence,  21  Northumberland  Street,  on  the  23rd  February,  after 
a  short  illness  of  ten  days'  duration. 

Dr  Sinclair  was  educated  at  the  Edinburgh  Academy,  and,  pur- 
suing his  studies  at  the  Edinburgh  University,  graduated  M.B., 
CM.  in  1868,  and  M.D.  in  1872.  During  the  two  years  following 
graduation  he  acted  as  Demonstrator  of  Anatomy  under  the  late  Dr 
Handyside,  a  position  which  he  filled  with  great  acceptance,  re- 
ceiving a  handsome  presentation  from  the  students  on  his  retire- 
ment. 

Having  thus  laid  the  foundation  of  that  accurate  knowledge  of 
his  profession  which  was  so  evident  to  all  who  came  in  contact  with 
him,  Dr  Sinclair  now  turned  his  attention  to  the  more  active  duties 
of  general  practice.  After  having  served  as  assistant  for  two  years 
to  Dr  Taylor,  Penrith,  he  settled  in  this  city  in  1872,  and  com- 
menced the  practice  of  his  profession  in  which  he  has  been  so 
successful. 

EDINBURGH   MED,  JOURN.,    VOL.  XXXIV. — NO.   X.  6  G 


970  OBITUARY.  [APRIL 

He  became  a  Fellow  of  the  Koyal  College  of  Physicians  in 
1874,  and  has  been  Examiner  in  Anatomy  and  Physiology  for 
that  body  during  many  years. 

He  was  connected  with  the  City  Parish  as  medical  officer  for 
sixteen  years,  and  at  his  death  held  the  position  of  Consultant  Phy- 
sician to  the  City  Poorhouse,  Craiglockhart.  Connected  with 
several  learned  societies,  viz.,  Royal  Medical,  Medico-Chirurgical, 
and  Obstetrical  (in  the  last  of  which  he  was  Vice-President  at  the 
time  of  his  death),  he  took  a  lively  interest  in  their  meetings,  and 
though  but  seldom  taking  active  part  in  their  debates,  his  occasional 
remarks  were  always  valuable  and  full  of  much  point. 

So  devoted  to  the  work  of  his  profession,  and  naturally  of  a  re- 
tiring character,  he  did  not  enter  much  into  society,  but  to  those 
who  were  fortunate  enough  to  know  him,  his  gentle  and  amiable 
disposition  will  long  be  remembered.  He  had  a  fund  of  quaint  and 
pleasant  humour,  absolutely  free  from  any  bitterness,  guile,  or  evil- 
speaking,  which  made  his  conversation  most  interesting. 

Respected  as  a  colleague,  revered  as  a  physician,  his  early  re- 
moval must  leave  a  blank  which  time  alone  can  efface. 

He  leaves  a  widow  and  three  children  to  mourn  his  loss. 


THE  LATE  DK  ARCHIBALD,  ST  ANDREWS. 

In  our  obituary  record  we  have  regretfully  to  notice  the  death  of 
an  old  and  greatly  esteemed  practitioner,  Dr  David  Archibald  of  St 
Andrews,  who  was  extensively  known  both  in  public  and  private 
life,  and  the  intimation  of  whose  death  has  evoked  the  sympathy 
and  sorrow  of  many  who  knew  his  genuineness  of  character  and 
high  moral  worth. 

Dr  Archibald  was  one  of  the  original  founders  of  the  Fifeshire 
Medical  Association,  of  v;hich  he  was  unanimously  and  early 
elected  the  President,  and  was  noted  for  his  regular  and  interested 
attendance,  as  well  as  for  the  urbanity  and  kind  hospitality  he  was 
always  ready  to  offer  to  the  members  and  other  professional 
brethren  visiting  St  Andrews,  where  he  delivered  a  presidential  ad- 
dress on  its  history,  and  the  best  means  of  promoting  the  interests 
and  fame  of  the  University. 

Dr  Archibald  became  a  member  of  the  Royal  College  of  Surgeons 
of  Edinburgh  in  1835,  and  took  his  degree  in  St  Andrews  in  1844. 
He  was  the  first  House  Surgeon  appointed  to  the  Dundee  Infirmary, 
and  afterwards  practised  with  great  acceptance,  for  a  number  of 
^ears,  in  Liff,  Forfarshire,  and  com.menced  practice  in  St  Andrews 
in  1853.  Since  then  and  until  quite  recently,  when  his  ill  health 
prevented  him  from  personally  fulfilling  his  numerous  duties,  he 
had  an  extensive  practice  in  the  city,  and  was  favourably  known 
throughout  the  county.  His  professional  career  was  contemporane- 
ous with  that  of  Drs  Adamson  and  Bell,  who  both  predeceased  him. 
For  many  years  he  acted  as  Medical  Officer  of  Health  to  the  St 


1889.]  THE   LATE   DR  ARCHIBALD.  971 

Andrews  and  St  Leonard's  Parochial  Boards,  and  always  took  a  lively 
and  kindly  interest  in  the  welfare  of  his  patients.  Dr  Archibald  was 
an  energetic  member  of  the  Town  Council  for  about  sixteen  years,  and 
was  identified  with  most  of  the  public  improvements  in  the  city  at  that 
time.  He  was  long  an  office-bearer  in  the  Church  of  Scotland.  In 
politics  he  was  a  strong  Conservative,  and  his  genial  face  will  be 
greatly  missed  in  Conservative  circles.  He  was  a  man  largely  gifted 
in  the  highest  sense,  self-sacrificing  and  guileless  even  to  a  fault,  but 
which  gained  the  affectionate  regard  of  those  who  best  knew  his 
estimable  character,  and  which  will  doubtless  be  long  and  kindly 
remembered.  For  the  past  three  years  he  has  been  in  declining 
health,  during  which  period  he  exhibited  wonderful  composure 
and  cheerfulness,  and  was  an  example  of  patient  endurance 
under  the  privation  of  his  usually  active  faculties.  He  was  in 
his  77th  year,  and  leaves  a  widow  and  family  of  two  sons  and  a 
daughter  to  mourn  his  loss.  His  remains  were  followed  to  the 
grave  by  old  professional  and  other  friends  from  a  distance,  the 
funeral  largely  partaking  of  a  public  character,  his  fellow-townsmen, 
together  with  the  volunteers,  of  which  he  was  Senior  Medical  Officer, 
attending  in  large  numbers  to  witness  his  being  laid  in  the  old  Catiie- 
dral  ground,  close  beside  the  last  resting-place  of  the  revered 
Principal  Tulloch,  whose  neighbourly  friendship  he  had  long  enjoyed, 
and  whose  valued  life  and  work  he  had  always  so  ardently  admired. 


DR  WILLIAM  DEWAE  OF  KIRKCALDY. 

This  most  estimable,  kind-hearted  practitioner  died  after  a  some- 
what lingering  chest  affection  on  March  19.  After  becoming  quali- 
fied in  1858,  Dr  Dewar  was  House-Surgeon  to  Professor  Syme, 
and  House-Physician  to  Dr  Keiller.  For  more  than  thirty  years 
Willy  Dewar,  as  all  his  friends  called  him  (and  he  had  no 
enemies),  practised  first  for  ten  years  in  Kinross,  and  for  the 
remainder  of  that  time  in  Kirkcaldy.  The  son  of  a  very  well- 
known  and  remarkable  father,  Dr  Dewar  of  Dunfermline,  he  was  a 
representative  of  a  family  of  Fife  doctors.  His  brother,  Dr  Dewar 
Durie,  practised  in  Dunfermline,  and  still  resides  at  his  family 
property.  Another  brother,  Dr  James  Dewar,  had  a  large  practice 
in  Kirkcaldy,  and  was  a  man  of  great  cleverness  and  large  medical 
experience.  He  died  some  years  ago,  and  his  practice  was  taken 
up  singlehanded  by  Dr  William  Dewar,  whose  departure  from 
Kinross  was  regarded,  as  a  genuine  loss  to  the  district,  and  he 
carried  with  him  to  his  new  and  more  extensive  field  of  labour  the 
genuine  respect  and  best  wishes  of  every  one  who  knew  him.  In 
Kirkcaldy  Dr  Dewar  rapidly  became  equally  popular,  and  his 
wide  circle  of  private  friends  and  patients  more  than  once  testified 
in  a  substantial  manner  their  high  appreciation  of  him.  In  par- 
ticular, he,  a  few  years  ago,  when  his  health  began  to  give  way, 
was  presented  by  his  patients  with  a  handsome  brougham  in  order 


972  OBITUARY.  [aPHIL 

that  he  might  continue  to  attend  to  his  practice  without  being 
unnecessarily  exposed  to  the  inclemency  of  the  weather.  A  keen 
sportsman  and  a  capital  rider,  Dewar  was  well  known  with  the 
Fife  hounds  and  as  Surgeon  to  the  Fife  Light  Horse.  Beloved 
both  by  his  patients  and  his  professional  brethren,  he  will  be  much 
missed  not  only  in  Kirkcaldy  but  in  the  whole  of  Fife.  He  died 
in  his  57th  year,  and  leaves  a  widow  and  four  children  to  mourn 
his  untimely  loss. 

DR  BONTHRON  OP  WEST  LINTON. 

Andrew  Bonthron,  M.D.,  died  on  February  15th  after  a  very 
short  illness,  aged  51.  This  is  the  sudden  ending  of  the  useful  life 
of  a  very  remarkable  man.  After  graduating  in  Edinburgh  in 
1860,  he  held  for  a  time  the  post  of  Resident  Surgeon  in  the  Sick 
Children's  Hospital,  and  then  for  more  than  a  quarter  of  a  century 
bore  the  burden  and  heat  of  the  day  in  an  extensive  and  therefore 
very  fatiguing  country  practice. 

With  a  very  quaint,  remarkable  exterior,  long  shaggy  hair,  a 
great  square  highly-colom'ed  face,  and  the  garments  of  a  game- 
keeper who  was  not  particular  as  to  his  externals,  with  habits  of 
irregular  hours  which  often  turned  night  into  day,  or  rather  used 
the  night  as  if  it  were  day,  with  a  most  curious  dislike  to  bed  and 
to  the  recumbent  posture,  which  made  him  sleep  at  odd  moments 
in  his  chair  and  not  go  to  bed  for  years. 

Still  Bonthron  was  a  man  of  great  ability,  unfailing  self-confidence, 
and  resource.  There  was  very  little,  even  in  an  obscure  case,  that  he 
had  not  discovered  and  set  down  at  its  proper  value,  while  both  his 
surgery  and  his  therapeutics  went  always  straight  to  the  mark.  His 
dress  and  habits  were  not  mere  eccentricities,  and  still  less  indications 
of  self-conceit,  but  were  the  outcome  of  a  philosophic  disregard  of 
paltriness  of  any  kind.  His  mental  capacity  was  of  a  type  that 
lived  rather  in  principles  than  in  details,  was  quite  above  the  ordinary, 
and  was  one  to  which  the  daily  routine  and  worry  of  an  extensive 
country  practice  must  have  implied  much  effort  and  self-sacrifice. 

He  tilled  his  place  in  the  world,  and  made  it  characteristic  in  a 
way  that  it  will  be  difficult  for  any  successor  to  emulate.  The  pity 
of  it  was  that  all  his  knowledge  and  experience  dies  with  him,  the 
profession  will  be  none  the  better  or  the  wiser,  as  he  was  one  of  the 
inarticulate  ones  who  neither  speak  nor  write. 


THE  LATE  DR  MUNRO,  RATHO. 

Robert  Munro,  L.F.P.S.G.,  died  somewhat  suddenly  on  the 
evening  of  March  6.  He  joined  the  profession  in  1859,  and  soon 
after  settled  in  Lochee,  near  Dundee.  But  the  best  part  of  his  life 
was  spent  in  Kinross,  where  for  sixteen  years  he  conducted  a  large 
practice  and  was  much  respected.     His  genial  manner  made  him 


1889.]  THE  LATE  DR  MtJNRO.  973 

welcome  in  every  home,  and  his  departure  in  1881  was  a  great  loss  to 
his  large  circle  of  friends.  Since  that  date  he  has  carried  on  practice 
in  Eatho,  in  succession  to  Dr  Shireff.  During  the  last  few  years 
symptoms  of  aortic  disease  became  developed  ;  recently  these  became 
aggravated,  and  he  had  been  advised  by  his  medical  attendants  to 
give  up  practice  altogether.  Arrangements  to  this  end  were  being 
made,  when  sudden  failure  of  the  heart's  action  occurred,  and 
death  ensued.  He  was  an  ardent  lover  of  Nature,  his  favourite 
study  being  botany.  This  love  of  natural  science  led  him  to 
spend  his  summer  holiday  in  parts  of  Scotland  congenial  to  such 
pursuits  ;  and  for  a  number  of  years  he  visited  tlie  Island  of  Arran, 
where  every  inch  of  the  soil  had  been  explored  by  him.  His  col- 
lection of  the  flora  of  Scotland  and  of  the  Island  of  Arran  in  par- 
ticular is  believed  to  be  most  complete.  He  leaves  a  widow 
and  family,  one  of  his  sons  being  a  qualified  medical  practitioner. 


DR  GEORGES  POINSOT  OF  BORDEAUX. 

Though  he  died  at  the  early  age  thirty-nine,  this  able  surgeon 
and  journalist  of  surgery  had  done  an  immense  amount  of  good 
work.  He  was  a  most  voluminous  author,  and  an  excellent  trans- 
lator of  English  standard  works  into  his  native  tongue.  An 
able  operator  and  teacher,  he  found  time  to  do  more  than  most 
men  who  have  reached  twice  his  age. 


CORRESPONDENCE. 


To  the  Editor  of  the  Edinburgh  Medical  Journal. 

THE  ARTICLE  "VACCINATION"  IN  TR^  ENCYCLOPEDIA 

BRITANNIC  A. 

Sm, — When  travelling  to  Canada  last  autumn  I  overheard  an 
observation  made  by  a  friend,  that  a  leading  Liberal  statesman  of 
ours,  while  he  personally  approved  of  vaccination,  deplored  the  com- 
pulsory law  which  prevailed  in  this  country  as  compared  with  the 
freedom  from  such  compulsion  which  existed  in  the  United 
States  of  America  and  in  Canada.  I  then  produced  a  letter  which, 
when  in  the  United  States  nearly  six  years  ago,  I  had  written 
home,  giving  an  account  of  the  stoppage  of  a  passenger  train  on 
the  Erie  Railway,  when  every  one  who  could  not  show  satisfactory 
marks  of  vaccination  was  then  either  vaccinated  or  revaccinated. 
On  making  inquiries  in  that  part  of  Canada  to  which  my 
business  called  me,  I  found  an  active  and  stringent  vaccination 
law  in  force  in  the  province  of  Manitoba;  and  there  I  was 
informed  that  similar  laws  were  to  be  found  in  operation  in  other 
provinces  of  the  Dominion.  Since  my  return  to  this  country  I 
have  had  the  vaccination  laws  of  Ontario  and  of  Quebec  sent  to 


974  CORRESPOND  ENCK.  [APRIL 

me,  and  obtained  in  London  the  vaccination  law  of  the  State  of 
Massachusetts. 

That  a  vaccination  law  with  very  plenary  powers  exists  in  the 
State  of  New  York  I  had  clear  practical  proof,  by  an  Eng- 
lish friend  informing  me  that,  owing  to  an  order  of  the  State 
Legislature  not  very  long  ago,  passengers  from  Canada  were  stopped 
at  Niagara  Falls,  and  that  in  order  to  avoid  examination  and  pos- 
sible revaccination  on  the  American  frontier,  he  had  to  procure  and 
have  in  his  possession  a  certificate  of  successful  vaccination  from  a 
doctor  of  medicine  in  Toronto, — all  those  failing  to  provide  such 
certificate  being  examined,  and,  if  thought  necessary,  vaccinated. 

As  letters  were  being  published  from  time  to  time  upon  the 
subject  of  vaccination,  I  meditated  writing  one  to  the  newspapers 
on  my  return  to  this  country  in  October  last,  along  with  the 
copy  of  the  Manitoban  Act  of  Parliament,  as  an  instance  of 
Transatlantic  legislation;  but  I  resolved  ultimately  to  wait 
until  the  last  volume  of  the  new  edition  of  the  Enmjdopcedia 
Britannica  appeared,  when  I  trusted  to  get,  under  the  head 
"  Vaccination,"  fuller  and  more  accurate  information  than  I,  a  mere 
casual  observer,  could  myself  collect. 

I  was  very  much  surprised  to  find  in  that  article  the  astounding 
statement,  that  "  only  in  few  states  or  cities  in  the  American  Union 
is  there  a  vaccination  Statute — in  Canada  there  is  none."  As  this 
was  clearly  opposed  to  fact,  I  drew  attention  to  the  error  in  the 
columns  of  the  Standard  newspaper,  a  proceeding  which  evoked 
an  angry  letter  from  the  "Writer  of  the  Article,"  in  which  he 
declared  I  had  found  a  couple  of  mare's  nests ;  and  that  although 
such  legislation  existed  in  Manitoba,  it  was  not  so  elsewhere  in 
Canada,  and  that  what  I  had  observed  probably  related  only  to 
school  children,  while  the  fact  as  to  the  stoppage  of  the  Erie 
train  in  United  States  territory  must  have  been  a  casual  one 
connected  with  immigration.  In  the  same  letter  he  says  that  he 
had  stated  the  fact  correctly  as  to  the  United  States,  but  his  only 
authority  appears  to  be  an  ex  parte  statement  from  a  Treatise  on 
Hygiene  by  a  Dr  Hamilton  of  New  York. 

Unfortunately  it  is  he,  not  Dr  Hamilton,  who  is  responsible 
for  the  ascertained  accuracy  of  statements  stereotyped  in  the 
Encyclopcedia  Britannica;  and  although  in  a  subsequent  letter 
he  was  extremely  angry  that  I  should  cast  doubts  on  the 
general  accuracy  of  an  important  medical  article  in  that  publica- 
tion, the  extreme  and  gratuitous  inaccuracy  of  his  statements  on  the 
subject  of  the  law  of  vaccination  is  quite  sufficient  to  inspire  one  not 
only  with  doubt,  but  with  deep  distrust,  of  all  his  other  statements. 

It  may  interest  your  readers,  therefore,  to  know  that  in  Canada 
where,  he  says,  there  is  no  vaccination  law,  I  am  able  to  make  two 
quotations  from  the  1885  Eeport  of  the  Medical  Health  Officer  of 
Montreal  (Province  of  Quebec) : — "  As  a  preventive  measure  against 
suiall-pox,  vaccination  is  undouhtedly  the  most  powerful  weapon  known 


1889.]  CORRESPONDENCE.  975 

to  science."  Judgments  are  recorded  as  having  been  given,  and 
penalties  imposed,  for  infringements  of  the  sanitary  laws,  one  of 
which  infringements  was,  "refusing  vaccination  for  themselves  or 
their  children." 

One  of  the  instructions  of  the  Central  Board  of  Health,  acting  under 
the  powers  of  the  law,  to  the  local  Boards  of  Health  and  its  officer  is, 
"  to  secure  a  prompt  vaccination  of  all  persons  who  have  been,  or  may 
be,  exposed  to  small-pox; "  and  "  to  take  steps  to  prevent  all  children 
coming  from  infected  houses  going  to  school,  and  to  vaccinate  all 
children  in  public  schools"  whenever  it  was  known  that  a  child  from 
an  infected  house  had  been  at  school.  So  much  for  the  province 
of  Quebec,  the  premier  province  of  Canada. 

We  now  come  to  the  rival  province  as  respects  importance  and 
population — the  province  of  Ontario.  There  is  a  Vaccination  Act 
there  also — Chapter  206  of  the  Eevised  Statutes  of  Ontario. 

In  the  abstract  of  Acts  in  force  respecting  vaccination  in  the 
province  of  Ontario,  it  is  stated  that  the  parents  or  guardians  of 
children  are  bound  to  have  them  vaccinated  within  three  mouths 
after  birth,  and  thereafter  to  produce  proof  of  successful  vaccina- 
tion, and  are  liable  in  penalties  for  non-compliance.  The  local 
authorities  may  order  the  vaccination  or  revaccination  of  all  per- 
sons within  their  jurisdiction  who  have  not  been  vaccinated  within 
seven  years — these  persons  are  bound  to  present  themselves  within 
seven  days  for  that  purpose,  subject  to  penalties  for  non-compliance, 
and  all  children  over  the  age  of  three  resident  in  a  municipality 
are  held  for  the  purposes  of  the  Act  as  children  born  there. 

Thus,  instead  of  there  being  no  vaccination  laws  in  Canada, 
we  find  such  laws  in  active  force  in  three  of  the  principal 
provinces — Quebec,  Ontario,  and  Manitoba;  and  I  have  very 
little  doubt  would  find  them  in  other  provinces  as  well.  The 
Manitoban  Act,  so  far  from  only  relating  to  school  children, 
provides  for  the  vaccination  of  all  children  within  three  months  of 
birth,  imposes  penalties,  and  cumulative  penalties,  for  non- vaccina- 
tion. Unvaccinated  children  are  not  permitted  to  attend  school. 
Teachers  are  bound  to  enforce  vaccination,  and  are  liable  for 
penalties  for  neglect  to  do  so.  The  Lieutenant-Governor  can  at 
his  discretion  order  a  wholesale  vaccination  of  the  inhabitants  of 
a  district ;  and  the  health  officer  can  obtain  the  aid  of  the  police 
to  carry  out  the  provisions  of  the  Act  46  &  47  Vict.  cap.  19. 

"What  can  be  said  to  the  writer  of  this  article  in  the  Encyclo- 
pcedia  for  making  such  a  statement  with  regard  to  Canada  in 
such  a  book,  and  defending  it  in  such  a  manner  ? 

And  now  we  turn  to  what  he  terms  the  other  "  mare's  nest" 
I  had  discovered,  viz.,  the  existence  of  vaccination  law  in  the 
United  States.  He  says  that  he  had  given  the  facts  correctly 
as  regards  the  United  States ;  and  in  his  letter  defending  the  article 
says,  "  For  example.  New  York  city  has  a  Board  of  Health  with 
vaccination  powers,  but  New  York  State  has,  or  recently  had,  none." 


976  CORRESPONDENCE.  [APRIL  1880. 

One  would  have  thought  that  the  fact  of  a  vaccination  law 
existing  in  the  principal  city  of  the  United  States  ought  to  have 
modified  very  largely  what  he  says  in  his  article  with  regard  to 
the  vaccination  law  of  the  United  States  generally ;  but  as  I  have 
shown  that  there  is  a  vaccination  law  in  the  State  as  well  as 
the  city  of  New  York  (Niagara  Falls  being  in  the  State  of  New 
York),  we  must  really  ask,  in  the  name  of  wonder,  where  the 
writer  of  the  article  got  his  information,  or  how  he  avoided  getting 
information  at  all  ?  Massachusetts  is  not  a  small  or  inconsiderable 
State  of  the  American  Union.  It  is  the  Mother  State  of  New 
England,  the  central  point  of  culture  and  education  of  the  great 
American  nation. 

I  have  the  Statutes  relating  to  the  public  health  of  the  State  of 
Massachusetts  before  me  as  I  write.  Under  these  Statutes  all  chil- 
dren are  to  be  vaccinated  before  they  attain  the  age  of  two  years; 
and  if  the  authorities  require  it,  after  five  years  from  the  last 
vaccination.  The  local  authorities  have  power  to  enforce  the 
vaccination  of  all  the  inhabitants  of  their  district ;  and  all  com- 
panies, schools,  prisons,  and  public  institutions  are  bound  to  cause 
their  employees  or  inmates  to  be  vaccinated  on  entry,  unless  they 
produce  satisfactory  evidence  of  previous  vaccination  within  five 
years.  I  should  like  to  know  what  some  of  our  friends  would  have 
said  if  Mr  Harrington  or  Mr  O'Brien  had  been  vaccinated  when 
they  entered  prison  ? 

Thus,  without  the  time  or  the  means  for  an"  elaborate  investiga- 
tion, such  as  is  due  to  the  preparation  of  an  article  in  the  Encyclo- 
pccdia  Britannica,  I  am  able  to  show  that  at  least  in  two  of  the  oldest 
and  most  civilized  of  the  States  of  the  American  Union  vaccination 
laws  of  a  very  stringent  character  have  existed  for  years.  These, 
so  far  as  Massachusetts  is  concerned,  are  no  novelties,  because 
chapter  117,  section  2,  Acts  of  1809  provides  for  the  "inoculation 
of  the  inhabitants  with  the  cow-pox." 

Before  closing  this  paper  I  would  notice  a  statement  made  by 
the  writer  of  the  article,  that  Dr  Jenner  traced  the  source  of  the 
vaccine  matter  to  the  greasy  heel  of  the  horse.  On  referring  to  the 
last  previous  edition  of  the  Encyclopcedia,  I  find  that  the  writer  of 
that  article  ascribes  not  to  Dr  Jenner,  but  to  a  Dr  Tanner,  the 
discovery  of  the  similar  action  of  matter  from  that  source  with  the 
action  of  cow-pox,  which  statement  is  correct. 

As  Mr  Picton,  M.P.,  has  given  notice  of  a  motion  on  the  20th 
inst,  for  an  inquiry  into  the  working  of  the  Vaccination  Law,  and 
as  I  observe  speakers  and  writers  are  founding  their  arguments  on 
the  strength  of  the  article  in  the  Encyclopcedia  Britannica,  it  does 
not  appear  useless  or  inopportune  thus  to  call  critical  attention 
to  the  whole  of  that  article,  as  well  as  to  the  portion  I  have  thus 
alluded  to. 

JAMES  GRAHAME. 

\bth  March  1889. 


|9att  jPttst. 

OEIGINAL    COMMUNICATIONS. 

I.— THE  HARVEIAN  ORATION  FOR  1889 :  Delivered  12th 

April. 

By  J.  Bell  Pettigrew,  M.D.,  LL.D.,  F.R.S.,  F.R.C.P.,  Laureate  of  the 
Institute  of  France ;  Chandos  Professor  of  Medicine  and  Anatomy,  and 
Dean  of  the  Medical  Faculty,  University  of  St  Andrews,  etc.,  etc. 

Gentlemen, — My  first  duty,  and  it  is  a  pleasant  one,  is  to  thank 
you  sincerely  for  the  honour  you  have  done  me  in  electing  me 
President  of  your  venerable  Society,  now  in  its  107th  session. 
As  Vice-President  I  have  had  few  cares,  and,  if  I  except  the 
difficulty  I  experienced  in  selecting  a  topic  for  the  present  address, 
no  troubles. 

My  first  impulse  was  to  prepare  a  scientific  paper  on  some  sub- 
ject connected  with  Harvey's  discoveries ;  but  a  little  reflection 
convinced  me  that  such  a  procedure  was  scarcely  suitable  to  au 
occasion  like  the  present,  when  our  duties  are  rather  retrospective 
and  social  than  prospective  and  scientific.  It  occurred  to  me  that 
I  might  not  inaptly  say  a  few  words  regarding  the  mighty  dead — 
the  great  pioneers  in  Medicine — to  whose  discoveries  we  profes- 
sionally are  so  much  indebted,  and  to  whom  humanity  at  large 
owes  an  everlasting  debt. 

The  Pioneers  in  Medicine  is  a  wide  subject — much  too  wide  for 
a  Harveian  OratioiL  I  have  consequently  resolved  to  confine  my 
observations  to  The  Pioneers  in  Medicine  prior  to  and  including 
Haroey. 

I  have  selected  the  early  pioneers  in  Medicine,  first,  because  in 
honouring  Harvey  we  should  bear  in  grateful  remembrance  those 
who  preceded  Harvey;  second,  because  the  history  of  Medicine 
is  better  known  since  than  before  the  days  of  Harvey ;  and,  third 
and  chiefly,  because  in  our  work-a-day  modern  world,  where  every 
one  jostles  his  neighbour,  occasionally  somewhat  roughly,  we  are 
too  apt  to  forget  the  claims  of  the  silent  departed.  While  enjoying 
the  fruits  of  their  labour,  we  unwittingly  ignore  the  workers  them- 
selves. In  other  words,  we  appropriate  and  profit  by  their  dis- 
coveries merged  in  the  common  stock  of  knowledge,  little  caring 
whence  the  knowledge  came.     In   this   respect  we   are   neither 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    XL  6  H 


978  PROFESSOR   PETTIGUEW'S   HARVEIAN    OKATION.  [MAY 

generous  nor  just,  for  every  one  knows  that  no  path  is  so  arduous 
as  that  of  the  original  inquirer,  and  whoever  elects  to  tread  it 
must  not  only  labour  incessantly,  but  deny  himself  continually. 

The  painful  fate  of  Socrates,  the  cruel  martyrdom  of  Servetus, 
and  the  persecution  and  untimely  death  of  Vesalius,  afford  examples 
of  men  who  have  sacrificed  their  all  for  the  sake  of  progress  and 
truth.  Verily,  the  path  of  the  discoverer  is  not  strewed  with 
flowers.  Nevertheless,  I  take  it,  that  every  original  inquirer  has 
his  reward,  if  not  in  worldly  goods  and  chattels,  in  high  commun- 
ings with  Nature,  and  in  the  deep  satisfaction  which  flows  from 
self-denial,  lofty  achievement,  and  a  sense  of  duty  done.  The 
heart  and  the  mind  are  both  expanded  by  contact  with  the  works 
of  the  great  First  Cause,  and  he  soon  comes  to  exclaim  with 
Coleridge : — 

"  He  prayeth  well  who  loveth  well 
Both  man  and  bird  and  beast, 
He  prayeth  best  who  loveth  best 
All  things  both  great  and  small, 
For  the  dear  God  who  loveth  lis 
He  made  and  loveth  all." 

It  may  truly  be  said  that  few  if  any  great  discoveries  are  made 
'per  saltum,  at  a  bound,  as  it  were.  They  for  the  most  part  filter 
through  many  men's  minds,  and  occasionally  at  long  intervals  of 
time.  As  the  mountain  is  formed  by  the  aggregation  of  indi- 
vidual particles  industriously  piled  up,  so  the  huge  tome  of  human 
knowledge  is  produced  by  the  aggregation  of  separate  discoveries, 
each  forming  an  integral  and  necessary  part  of  the  whole.  One 
discovery  leads  to  another,  and  thus  it  happens  that,  as  civilisation 
advances  and  time  grows  older,  the  tiny  rills  of  human  knowledge 
widen  into  the  brimming  river,  the  brimming  river  into  the  broad 
estuary,  and  the  broad  estuary  into  the  practically  boundless 
ocean  of  universal  truth. 

The  discoveries  of  the  ancients  were  unimportant  when  compared 
with  those  of  modern  times ;  but  who  shall  say  that  the  early  dis- 
coveries were  not  essential  to  the  later  discoveries,  and  that  without 
them  the  later  discoveries  could  not  have  been  made.  To  take 
examples,  where  would  that  wonderful  instrument  the  phonograph, 
invented  by  Bell  and  perfected  by  Edison,  have  been  to-day,  but 
for  a  knowledge  of  the  human  voice,  and  ear,  and  the  laws  of 
acoustics  ?  Where,  moreover,  would  that  mysterious  and  far- 
reaching  instrument,  the  modern  telegraph,  have  been  without  a 
knowledge  of  electricity  ?  Nay,  more,  where  would  electricity 
itself — the  veritable  fire  of  heaven — have  been  but  for  a  knowledge 
of  the  laws  of  motion  and  the  transformation  of  energy  ?  From 
small  beginnings  the  very  greatest  results  may  ultimately  flow ; 
and  for  this,  if  for  no  other  reason,  we  are  bound  to  honour  the 
discoveries,  be  they  great  or  small,  of  the  ancients  in  Medicine  as 
in  all  other  departments  of  learning. 


1889.]  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  979 

Discovery  and  knowledge  are  cumulative  in  the  sense  that 
capital  at  compound  interest  is  cumulative.  This  follows  because 
history  records  and  treasures  up  the  rich  stores  of  knowledge  of 
one  generation,  and  offers  them  as  free  gifts  to  every  succeeding 
generation, — succeeding  generations  of  men  being,  as  it  were, 
arranged  in  tiers,  the  last  being  always  on  a  higher  level  than  its 
predecessor,  and  having  as  a  consequence  a  more  exalted  and 
wider  range  of  vision  and  of  subject.  The  advances  made  of  late 
years  in  every  department  of  science,  Medicine  included,  have  been 
so  extensive  and  in  some  cases  so  astounding,  that  it  is  difficult  to 
say  wliat  will  occur  next.  As  Disraeli  was  wont  to  declare  in  his 
epigrammatic  way,  "  The  unexpected  always  happens."  If  any  one 
had  ventured  to  predict  fifty  years  ago  that  all  the  major  operations 
in  surgery  would  be  performed  painlessly  by  simply  inhaling  an 
anaesthetic,  or  that  by  employing  antiseptics  a  limb  could  be 
amputated  and  the  stump  healed  without  the  appearance  of  a  single 
drop  of  pus  or  the  faintest  trace  of  a  disagreeable  odour,  he  would 
straightway  have  been  considered  a  fit  subject  for  confinement. 

If  it  is  true  that  great  discoveries  are  seldom  the  product  of  one 
mind,  it  is  no  less  true  that  great  discoveries  seldom  or  ever  stand 
alone.  Each  discovery  has,  so  to  speak,  its  approaches,  its  environ- 
ments in  time  and  space,  and  in  the  idiosyncrasies  of  the  human 
race.  The  nature  of  things  demands  this.  The  matter  and  force 
of  the  universe  are  fixed  quantities,  admitting  of  change  of  shape 
and  change  in  direction,  and  the  intellectual  forces  which  operate 
on  these  entities  have  a  common  substratum,  and  differ  less  in  kind 
than  in  degree.  As  a  corollary  to  this  state  of  matters,  it  happens 
that  all  conscious,  rational  beings  think  about  themselves  or  the 
universe  of  which  they,  from  their  composition,  are  to  be  regarded 
as  integral  parts.  Similarly  constituted,  and  dealing  essentially 
with  the  same  matter  and  force,  large  numbers  of  men  think  in 
common,  and  their  ideas  being  expressed  and  recorded,  come  in 
this  way,  naturally  and  unwittingly,  to  form  the  data  for  discovery. 
It  was  doubtless  this  perpetual  recurrence  of  ideas  with  a  common 
basis — this  everlasting  flux  of  the  same  matter  and  force  in  the 
same  universe — which  led  that  prince  of  philosophers,  the  wise 
Solomon,  to  declare,  with  all  seriousness,  that  there  is  "  nothing 
new  under  the  sun."  And  apropos  of  this,  it  may  be  well  to  state, 
as  teaching  humility  and  a  becoming  reverence,  that  even  the 
greatest  discoverer  cannot  discover  anything  which  does  not  already 
exist.  This  follows  because  man  creates  nothing.  He  only  sees 
with  the  human  eye,  and  perceives  by  the  human  brain,  what  is 
already  made ;  and  this  explains  why  the  highest  order  of  genius 
is,  as  a  rule,  the  most  diffident,  and  how  the  most  learned  and  the 
most  sagacious  of  men  are  almost  without  exception  the  most 
humble.  The  profound  Newton  affords  a  striking  example  of  the 
belief  here  expressed.  With  all  his  learning  and  power,  and  they 
were  stupendous,  he  regarded  himself,  even  in  advanced  years,  as 


980  PROFESSOR   PETTIGREW'S   HA.RVEIAN   ORATION.  [MAY 

a  little  child  gathering  pebbles  at  the  margin  of  the  great  ocean  of 
truth. 

The  early  history  of  Medicine  is  necessarily  very  obscure,  and  I 
do  not  propose  to  refer  to  it  as  it  existed  in  tradition  and  myth 
among  the  ancient  Egyptians  and  the  very  antiquated  Chinese. 
My  observations  will  be  confined  to  what  may  be  called  the  more 
strictly  historic  period.  Medicine  being  more  or  less  of  a  universal 
subject,  its  ramifications  are  necessarily  philosophic  and  scientific. 
It  will  occasion  no  surprise,  then,  if  at  one  time  we  find  philo- 
sophers contributing  to  Medicine,  and  at  another  time  physicians 
contributing  to  philosophy. 

-^sculapius  and  Pythagoras  fall  first  to  be  considered,  but  behind 
and  towering  above  both  appears  Hippocrates,  the  mighty  father 
of  Medicine.  He  stands  alone,  like  a  great  oak  in  a  wide  chase, 
or  an  eagle  perched  in  solitary  grandeur  on  the  loftiest  peak  of  a 
lofty  range.  Of  >^sculapius,  the  reputed  founder  of  Medicine  and 
Surgery,  little  or  nothing  is  known  beyond  the  fact  that  he  was 
born  in  Thessaly.  Indeed,  according  to  Cicero,  there  were  no  less 
than  three  individuals  of  that  name,  all  of  them  celebrated  for  their 
proficiency  and  skill  in  medicine.  On  the  death  of  ^sculapius  he 
was  deified,  and  temples  were  erected  to  his  memory  in  various 
places.  At  these  temples  priest-physicians  officiated,  the  temples 
ultimately  becoming  schools  of  medicine,  it  being  a  condition  that 
every  one  successfully  treated  presented  a  votive  tablet  to  the 
temple,  recording  the  history  of  the  case,  and  giving  a  drawing 
and  model  thereof.  These  tablets  formed  so  many  illustrated 
clinical  reports,  and  proved  of  the  utmost  value  to  all  those  who 
followed.  The  medical  priests,  with  a  view  to  securing  power  and 
obtaining  wealth,  unfortunately  mixed  with  their  practice  a  large 
amount  of  superstition,  divination,  and  falsehood;  and  thus  it 
happened  that,  in  the  lapse  of  time,  the  pure  teaching  and  wise 
example  of  ^sculapius  were  disregarded,  and  the  temples  medically 
polluted, — a  state  of  matters  which  was  only  corrected  some  cen- 
turies after  by  the  single-minded  Hippocrates.  The  descendants  of 
-^sculapius,  who  formed  the  medical  priesthood,  came  to  be  known 
as  the  JEsclepiadse,  the  medical  schools  being  designated  -^Esclepia. 
The  -i^sclepiadse  numbered  in  their  ranks  many  of  the  most 
celebrated  men  of  antiquity,  such  as  Hippocrates,  Aristotle,  Xeno- 
phon,  Heraclides,  Praxagoras,  etc. 

Among  the  sages  of  antiquity  few  are  entitled  to  a  more  honoured 
place  than  Pythagoras,  born  570  years  before  the  Christian  era. 
Pythagoras  was  a  philosopher  and,  in  some  senses,  a  physician. 
Actuated  by  the  highest  motives  and  inspired  by  an  ardent  thirst  for 
knowledge,  he  travelled  in  Egypt,  India,  and  other  eastern  countries; 
for  in  these  countries,  and  not  in  Greece  at  that  early  day,  were 
the^stores  of  human  knowledge  accumulated  and  treasured.  On 
his  return  to  Europe,  Pythagoras  introduced  the  doctrine  of 
metempsychosis   or  transmigration   of  souls.     He   was  great   in 


1889.]  PUOFESSOR   PETTIGREW'S   HARVEIAN   OKATION.  981 

numbers,  formulated  a  system  of  dietetics,  and  founded  a  scliool 
at  Crotona  in  Italy.  At  this  school  he  taught  the  theory  if  not 
the  practice  of  Medicine;  and  it  is  known  that  he  dissected  animals, 
and  that  some  of  his  pupils,  Alcmaon,  e.g.,  acquired  a  considerable 
knowledge  of  comparative  anatomy.  It  is  not  supposed  that 
Pythagoras  or  any  of  his  pupils  got  the  length  of  dissecting  the 
human  body — the  human  cadaver  among  the  Greeks  being,  to  a 
large  extent,  a  sacred  subject. 

With  the  advent  of  Hippocrates  a  new  era  dawned  for  Medicine. 
This  particular  medical  star  was  born  at  Cos,  in  the  ^gean 
Sea,  about  460  B.C.  He  was  the  first  to  successfully  combat  the 
dangerous  doctrine  of  the  celestial  origin  of  disease,  taught  by  the 
medical  priesthood,  and  expressly  stated  that  "  no  disease  comes 
from  the  gods,  one  more  than  another,  each  acknowledging  its  own 
natural  and  manifest  cause."  He  remarks  that  our  chief  study 
should  be  to  acquire  a  knowledge  of  the  true  properties  of  things, 
not  by  vain  theories,  but  by  patient  investigation,  actual  experi- 
ment, and  careful  induction.  Hippocrates,  in  fact,  applied  the 
inductive  method  of  reasoning  to  Medicine ;  and  if  his  disciples 
had  fully  comprehended  and  followed  his  instructions,  they  would 
have  laid  the  foundations  of  an  analytical  philosophy.  Hippo- 
crates not  only  noted  the  connexion  and  dependence  of  facts 
observed  by  himself  and  others,  but  he  drew  legitimate  conclusions 
therefrom.  He  observed,  experimented,  and  wrote  largely;  but 
unfortunately  the  exact  number  of  his  works  cannot  be  determined. 
His  text  has  also  in  many  cases  been  tampered  with.  In  those 
works,  which  are  believed  to  be  authentic,  he  ascribes  all  the 
phenomena  of  life  and  health  to  the  operation  of  a  fundamental 
principle,  which  he  denominates  Nature;  and  this  principle, 
implanted  in  all  animals,  is,  according  to  him,  sufficient  for  their 
preservation,  as  apart  from  education,  leading  them  to  appropriate 
and  assimilate  what  is  good,  and  to  reject  and  extrude  what  is 
inimical  and  bad.  These  views  involve  the  doctrines  of  depura- 
tion, concoction,  and  crisis  promulgated  by  Hippocrates  and  his 
followers.  Hippocrates  insisted  much  upon  diet,  and  made  it  the 
fulcrum  of  his  practice.  He  also  attached  great  importance  to 
bathing,  exercise,  and  fresh  air.  Perhaps  his  chief  merit  consisted 
in  his  patient  industry  in  watching  the  phases,  and  accurately 
recording  the  progress  and  results  of  disease ;  in  noting  the  signs 
and  symptoms  of  disease  before  it  developed  itself,  and  while  it 
was  running  its  course ;  in  observing  what  alleviated  and  what 
aggravated  disease, — a  mode  of  procedure  which  enabled  him  to 
predict  the  nature  of  the  coming  malady,  and  to  anticipate  the 
time  and  manner  of  its  termination.  Hippocrates  was  great  in  his 
knowledge  of  signs  and  symptoms,  and  a  typical  example  of  the 
intellectual  clinical  physician.  He  distinguished  four  different 
stages  in  disorders,  to  wit,  their  beginning,  increase,  height,  and 
decline.     When  the  complaint  exceeded  sixty  days  he  regarded 


982  PROFESSOR   PETTIGREW'S   IIARVEIAN   ORATION.  [MAY 

it  as  chronic.  His  knowledge  of  disease  was  based  upon  the 
appearance  of  the  patient,  the  posture,  the  nature  of  the  pulse  and 
excrementitious  discharges,  such  as  the  urine,  faeces,  expectoration, 
and  sweat.  He  traced  disease  to  the  humours  of  the  blood  and 
bile,  to  errors  of  diet,  and  tlie  want  of  fresh  air  and  exercise. 

Among  his  aphorisms  for  the  cure  of  disease  may  be  mentioned 
the  following : — 

"  Contraries  or  opposites  are  remedies  for  each  other, — evacua- 
tion being  the  remedy  for  repletion,  and  repletion  for  depletion." 

"  Physic  should  take  away  what  is  redundant  or  supply  what  is 
deficient." 

"When  reason  approves  a  certain  course  of  treatment,  the 
treatment  should  not  be  abandoned  hastily." 

"  It  is  the  duty  of  the  physician  to  note  what  affords  relief  and 
what  causes  pain,  and  frequently  to  pause  and  observe,  as  in  this 
way  he  at  least  does  no  harm." 

Hippocrates  administered  emetics  once  or  twice  a  month  to 
persons  of  vigorous  constitution,  in  winter  and  spring.  He  gave 
purges,  not,  however,  during  the  dog  days  or  to  pregnant  women, 
and  he  seldom  purged  infants  or  very  old  people,  He  bled  in 
dropsy,  enlargement  of  the  spleen,  etc.,  the  veins  on  which  he 
operated  being  those  of  the  arms,  hands,  forehead,  back  of  head, 
behind  the  ears  and  under  the  breasts,  ankles,  and  hams.  He 
also  employed  cupping  and  scarifying.  If  purging  and  bleeding 
failed,  he  resorted  to  diaphoretics  and  diuretics,  and  in  certain 
cases  to  specifics.  His  external  remedies  consisted  of  fomenta- 
tions, fumigations,  gargles,  oils,  ointments,  cataplasms,  and  collyria 
or  eye  washes.  These  were  the  chief  Hippocratic  remedies,  and 
they  form  a  battery  at  once  offensive  and  defensive,  of  which  no 
modern  physician  need  be  ashamed. 

Hippocrates  is  said  to  have  been  the  first  of  the  authors  whose 
works  have  descended  to  us  who  has  treated  the  subject  of  anatomy 
with  anything  like  the  precision  of  a  science.  That  he  dissected 
a  large  number  of  animals  there  is  no  room  to  doubt,  and  that 
he  had  a  knowledge  of  the  human  skeleton  is  evinced  by  the 
brazen  model  of  a  skeleton  which  he  hung  up  in  the  temple  of 
the  Delphian  Apollo.  It  is  not,  however,  established  that  he 
dissected  the  human  body,  and  the  contrary  seems  more  likely 
from  certain  errors  in  his  writings,  and  from  his  followers  not 
excelling  in  anatomy  as  they  did  in  the  practice  of  physic. 

Hippocrates  had  a  knowledge  of  the  circulation,  though  neces- 
sarily an  imperfect  one.  Thus,  in  his  book  on  the  Heart  (-Trepi 
KapSit]<;)  he  speaks  of  that  viscus  as  consisting  of  a  thick  and 
strong  muscle  having  auricles  and  ventricles — the  ventricles  being 
divided  by  a  dense  septum ;  the  auricles  and  ventricles  giving  rise 
to  the  great  vessels  of  the  heart  and  lungs,  and  which  have  valves 
at  their  roots  to  keep  out  the  in-breathed  air.  In  the  book  on 
Nourishment  (Tre/at  Tpo(piji)  the  arteries  are  spoken  of  as  ^Xe/Se?, 


18.S9.]  PUOFESSOK  PETTIGREW'S   HARVEIAN   OKATION.  983 

the  term  aprepia  being  applied  to  the  windpipe  and  bronchial 
tubes.  In  this  way  the  blood  and  air-passages  and,  to  a  certain 
extent,  their  contents,  got  mixed  up  in  the  mind  of  Hippocrates, 
the  veins  being  supposed  to  contain  blood  which  nourished  every 
part  of  the  body,  the  arteries  containing  blood  with  a  large  admix- 
ture of  air,  otherwise  called  vital  spirit,  which  heated  every 
part  of  the  body.  This  view  was  partly  founded  on  the  fact 
that  when  animals  are  killed,  but  not  bled  to  death,  very  little 
blood  comparatively  is  found  in  the  arteries,  by  much  the  larger 
quantity  being  found  in  the  veins.  The  vessels  in  the  book  on 
Nourishment  are,  curiously  enough,  described  as  arising  not  from 
the  heart,  but  from  the  head  and  other  regions  of  the  body,  it  being, 
as  Hippocrates  states,  difficult  to  say  where  vessels  rise  and 
end,  "  for  in  a  circle  you  find  no  beginning."  The  latter  phrase, 
coupled  with  the  statement  that  the  heart  and  vessels  manifest 
motion  and  carry  blood  and  spirit,  has  led  some  authors  to  assert 
that  Hippocrates  was  acquainted  with  the  circulation  as  subse- 
quently discovered  by  Harvey,  which  is  of  course  erroneous. 

Hippocrates  regarded  the  heart  as  the  fountain  of  the  blood 
and  the  source  of  the  native  heat,  the  heart  being  surrounded  by 
the  lungs  with  a  view  to  tempering  its  heat  or  keeping  it  cool. 
He  believed  the  arteries  to  be  charged  with  heat,  and  speaks  of 
them  as  venulce  calidiores.  The  fact  that  the  text  of  Hippocrates 
has  in  many  cases  been  tampered  with,  renders  it  next  to  impos- 
sible to  ascertain  the  precise  extent  of  his  knowledge  regarding 
the  circulation.  This,  however,  matters  little.  Enough  is  known 
to  place  Hippocrates  in  the  loftiest  niche  of  the  .^sculapian 
temple.  His  will  always  be  a  colossal  figure  in  Medicine.  If  his 
lamp  has  been  dimmed  by  the  splendid  electric  glow  of  modern 
science,  it  is  safe  to  predict  it  will  never  be  wholly  extinguished. 
Hippocrates,  whose  genius  and  sterling  worth  have  commanded 
the  admiration  of  all  ages,  is  said  to  have  attained  the  remarkable 
age  of  101  years,  and  to  have  died  at  Larissa  in  Thessaly  about 
359  B.C. 

Plato,  the  great  idealist,  born  427  B.C.,  was  not  a  physician,  but 
deserves  a  passing  word  from  having  contributed  his  quota  to  the 
circulation  of  the  blood.  In  the  Timseus,  Plato  says  the  heart  is 
the  fountain  of  the  blood,  and  gives  rise  to  the  containing  vessels 
^Xe/3e9 — arteries  and  veins.  He  further  states  that  the  heart  sets 
the  blood  in  motion,  an  observation  strangely  overlooked  by  many 
of  his  successors.  He  called  the  great  artery  of  the  body  Aorta 
(its  present  name),  and  when  speaking  of  it  adds  that  "  the  blood 
is  forcibly  carried  round  to  all  the  members — to  aifia  Kara  Trdvra 
ra  juieXa  a-^oSpm  TrepicpepecrOai"  a  remark  which  has  induced 
some  to  hazard  the  opinion  that  Plato  was  acquainted  with  the 
circulation  of  the  blood  as  we  now  know  it.  This  could  scarcely 
be,  as  knowledge  so  important  would  from  its  precious  nature 
have  been  carefully  preserved,  inculcated,  and  transmitted. 


to 


984  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [.MAY 

Plato  assigns  three  ventricles  to  the  heart, — a  mistake  probably 
owing  to  his  having  examined  the  hearts  of  reptiles  with  three 
cavities,  there  being  no  evidence  to  show  that  he  ever  dissected 
the  human  body. 

The  great  Stagyrite  Aristotle,  the  scholar  of  Plato,  and  the  typical 
philosopher  and  scientist  in  one,  has  also  something  to  say  of  the 
heart,  and  in  addition  of  the  respiration  and  digestion.  Aristotle 
was  born  at  Stagyra  384  B.C.,  and  died  322  B.C.  He  regards  the 
heart  as  the  source  and  reservoir  of  the  blood,  it  being 
the  only  viscus  which  contains  blood.  Like  Plato  he  desig- 
nates the  vessels  0Xe/3e9 — arteries  and  veins,  but  he  distin- 
guishes between  the  two  sets  of  vessels  and  regards  them  as 
complementary,  the  one  existing  for  the  other.  He  also  regards 
the  heart  as  the  seat  and  source  of  the  native  heat,  the  beating  of 
the  heart  being  due,  in  his  opinion,  to  the  sudden  expansion  of 
relays  of  digested  food  from  the  stomach  supplied  for  the  elabora- 
tion of  the  blood  coming  in  contact  with  the  superheated  viscus. 
The  arteries,  according  to  him,  pulsated  synchronously  with  the 
heart,  the  blood  flowing  alternately  from  the  vessels  to  the  heart, 
and  from  the  heart  to  the  vessels  (a  to  and  fro  movement),  the 
valves  of  the  heart  being  so  disposed  that  one  set  was  opened 
while  another  was  closed,  the  set  which  was  opened  the  one 
instant  being  closed  the  next,  and  the  converse,  with  the  result 
that  the  current  of  the  blood  was  regulated. 

Aristotle  associated  the  beat  of  the  heart  with  the  respiratory  pro- 
cess, one  object  of  the  respiration  being  to  cool  or  temper  the  heat  of 
the  heart  always  tending  to  excess.  "The  hotter  the  animal,"  he  says, 
"  the  more  vigorously  must  it  breathe  in  order  the  more  effectually 
to  subdue  the  heat,  whence  the  larger  development  of  the  lungs 
in  quadrupeds  and  birds  than  in  amphibious  animals."  The  air 
in  the  lungs,  Aristotle  maintained,  was  necessary  for  the  produc- 
tion of  the  vital  spirit  (part  blood  and  part  air),  which  bulked 
so  largely  in  the  physiology  of  the  heart  and  the  circulation 
among  the  ancients.  He,  however,  showed  that  there  was  no 
direct  communication  between  the  bloodvessels  and  the  ramifica- 
tions of  the  trachea  in  the  lungs,  the  air  acting  on  the  blood  by 
contact  and  a  kind  of  sweating  or  insudation. 

Aristotle  supports  what  he  says  regarding  the  heart  and  the 
circulation  by  important  observations  on  the  lacteal  vessels.  In 
his  numerous  dissections  of  the  lower  animals  he  not  only  dis- 
covered, but  gave  a  rational  explanation  of  the  uses  of  those  vessels. 
He  had  observed  the  lacteal  vessels  in  the  mesentery,  and  con- 
cluded that  they  terminated  in  the  vena  cava  and  aorta.  He  was 
wrong  in  his  anatomy,  but  as  the  following  remarks  prove  he  was 
right  in  his  physiology.  Likening  the  lacteals  to  the  roots  of 
plants,  he  says,  "  Even  as  plants  draw  nourishment  by  their  roots 
from  the  ground,  so  animals  derive  nourishment  from  the  stomach 
and  intestines,  these  standing  to  them  in  lieu  of  the  earth,  and 


188!).]  PKOFESSOE  PETTIGREW's   HARVEIAN   ORATION.  985 

having  veins  in  the  guise  of  roots  implanted  in  their  substance."  ^ 
Aristotle,  it  will  be  seen,  had  a  shrewd  general  idea  of  the  circula- 
tion, respiration,  and  digestion.  He,  strangely  enough,  held  that 
the  nerves  rose  from  the  heart,  an  opinion  no  doubt  partly  due  to 
the  prevailing  belief  that  the  heart  was  the  seat  of  the  emotions 
and  passions. 

Theophrastus,  one  of  Aristotle's  pupils,  born  373  B.C.,  contri- 
buted largely  to  the  advance  of  Medicine  by  founding  the  science 
of  botany. 

Diodes,  a  contemporary  of  Plato,  who  flourished  370  B.C.,  de- 
voted much  of  his  time  to  comparative  anatomy,  and  wrote  a 
manual  on  the  dissection  of  dead  bodies. 

At  this  period  also,  Praxagoras,  of  Cos,  lived  and  laboured.  He 
seems  to  have  derived  his  knowledge  from  an  inspection  of  the 
human  body,  and,  while  distinguishing  more  carefully  than  his 
predecessors  as  between  arteries  and  veins,  was  the  first  to  employ 
the  term  pulse  in  the  modern  sense.  He  believed  that  the  arteries 
pulsated  of  themselves,  that  they  rose  in  the  lungs  and  terminated 
in  the  nerves;  the  nerves  in  turn  having  their  origin  in  the  heart, 
which  was  also  the  opinion  of  Aristotle.  Praxagoras  regarded  the 
respiration  as  necessary  to  the  production  of  the  so-called  vital 
spirit ;  vital  spirit,  there  is  reason  to  believe,  being,  as  already 
stated,  an  attenuated  mixture  of  blood  and  air,  elaborated  in  some 
mysterious  way  between  the  right  side  of  the  heart  and  the  lungs. 

Herophilus  and  Erasistratus  were  the  first  to  dissect  the  human 
body,  and  it  has  been  averred  that,  in  some  cases,  they  even  dis- 
sected living  criminals.  They  flourished  at  Alexandria  under  the 
Ptolemies  about  300  B.C.,  and  enjoyed  splendid  opportunities,  as  at 
that  time  the  magnificent  Alexandrian  Library  was  founded,  and 
medical  schools  and  hospitals  established  on  a  large  scale. 

Herophilus,  a  native  of  Carthage,  was  believed  to  have  been  a 
pupil  of  Praxagoras,  and  his  name  is  associated  with  a  complicated 
set  of  vessels  in  the  brain,  the  Torcular  Herophili.  Galen  speaks  of 
him  '*  as  an  accomplished  man  in  all  branches  of  physic,  excelling 
particularly  in  anatomy,  which  he  learned,  not  from  the  dissections 
of  beasts  alone,  as  physicians  usually  do,  hitt  principally  from,  that 
of  men.'"^  The  discovery  of  the  real  nerves  which  were  unknown 
to  Hippocrates  and  Aristotle  is  attributed  to  him.  According  to 
Eufus  of  Ephesus,  he  arranged  them  into  three  divisions : — 1st,  The 
nerves  of  sensation  and  motion,  originating  in  the  cerebrum,  cere- 
bellum, and  spinal  cord.  2nd,  The  nerves  which  could  not  be  traced 
either  to  the  encephalon  or  spinal  cord,  but  which  communicated 
sensation  and  obeyed  the  commands  of  the  will.  3rd,  Nerves  which, 
in  all  likelihood,  represented  tendons  and  ligaments.  He  described 
the  optic  nerve  and  retina  with  considerable  care,  and  believed  the 
brain  to  be  the  seat  of  the  soul — the  ventricles  of  the  brain,  accord- 

*  De  Eespir.,  caps.  ix.,xix.,  xx.  ;  De  part.  Animal,  lib.  iv.  cap.  4. 
^  Galen  de  dissedione  Vulvae,  cap.  v. 

EDINBURGH   MED.    JOURN.,   VOL.   XXXIV. — NO.    XI.  6  I 


086  PHOFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [MAY 

ing  to  liim,  being  its  peculiar  habitat.  He  also  gave  a  rational 
explanation  of  the  pulse,  referring  it  to  the  beat  of  the  heart. 

The  renowned  Fallopius,  one  of  the  best  anatomists  of  the  six- 
teenth century,  was  a  staunch  believer  in  Heropliilus,  and  declared 
that  it  would  l3e  as  unreasonable  to  contradict  him  on  a  point  of 
anatomy  as  it  would  be  to  contradict  the  Gospels. 

Erasistratus,  who  flourished  300  B.C.,  was,  like  Herophilus,  a 
physician  and  anatomist  of  the  first  order.  He  divided  the  nerves 
into  two  sets,  viz.,  those  which  are  the  organs  of  sensation,  and 
those  which  are  the  organs  of  motion.  His  description  of  the 
brain  for  tliis  early  period  is  so  striking  that  I  venture  to  transcribe 
it  intact. 

He  remarks : — "  We  examined  what  the  nature  of  the  human 
brain  was,  and  we  found  it  divided  into  two  parts,  as  it  is  in  all 
other  animals.  Each  had  a  ventricle  or  cavity  of  a  longitudinal 
form. 

"  These  ventricles  had  a  communication  wnth  each  other,  and 
terminated  in  a  common  opening,  according  to  the  contiguity  of 
their  parts,  reacliing  afterwards  to  the  cerebellum,  where  there  was 
also  a  small  cavity ;  but  each  part  was  separated  from  the  other, 
and  shut  up  in  its  proper  membranes ;  and  the  cerebellum  in  par- 
ticular was  so  wrapped  up  by  itself,  as  well  as  the  brain,  which 
by  its  various  windings  and  turnings  resembled  the  intestinum 
jejunum. 

"  The  cerebellum  was  in  like  manner  folded  and  twisted  dif- 
ferent ways,  so  that  it  was  easy  to  know,  by  seeing  it,  that,  aa  in 
the  legs  of  swift-running  animals — as  the  deer,  the  hare,  and  some 
others — we  observe  the  tendons  and  muscles  well  calculated  for 
that  purpose  ;  so  in  man,  who  has  a  larger  share  of  understanding 
than  other  animals,  this  great  variety  and  multiplicity  of  foldings 
in  the  brain  was  undoubtedly  designed  for  some  particular  end. 

"  Besides,  we  observed  all  the  apophyses,  or  productions  of  the 
nerves,  which  come  from  the  brain ;  so  that,  to  state  all  at  once, 
the  brain  is  visibly  the  principle  of  everything  that  passes  in  the 
body;  for  the  sense  of  smelling  proceeds  from  the  nostrils,  being 
pierced  in  order  to  have  communication  with  the  nerves ;  the 
sense  of  hearing  is  also  produced  by  the  like  communication  of 
the  nerves  with  the  ears ;  the  tongue  and  the  eyes  receive  also  the 
productions  of  the  nerves  of  the  brain." 

Erasistratus  described,  with  considerable  fidelity,  the  valves  of 
the  heart,  and  was  evidently  acquainted  also  with  the  valves  of  the 
veins  ;  the  function  of  the  valves  in  all  cases  being,  he  explained, 
to  regulate  the  flow  of  the  blood  and  vital  spirit,  and  to  prevent 
regurgitation.  Speaking  of  the  valves  of  tlie  heart  {valvulce  vetiosce), 
he  says  they  give  ready  access  to  the  ventricles  from  without,  and 
effectually  prevent  regurgitation  from  within.  He  also  adds  that 
tiie  arteries  have  an  independent  power  of  pulsating,  the  veins 
being  purely  passive  channels.     Ignorant,  however,  of  the  true 


188;).]  PROFESSOR   PETTIGREW'S    IIAUVEIAN    ORATION.  987 

nature  of  the  circulation,  and  misled  by  a  common  belief,  he  was 
of  opinion  that,  in  the  normal  state  of  the  body,  the  arteries  for 
the  most  part  contained  air.  The  vena  cava,  according  to  him, 
was  the  great  reservoir  of  the  blood,  while  the  aorta  was  the  great 
reservoir  of  the  vital  spirits.  The  blood  and  spirits  only  inter- 
mingled when  the  system  was  disordered,  and  the  function  of  the 
respiration  was  to  supply  air  to  the  arteries.  If  an  artery  was 
wounded,  the  vital  spirits,  he  said,  escaped,  and  then,  and  then 
only,  the  blood  in  the  veins  rushed  into  the  artery  to  supply  their 
place.  His  ideas  of  digestion  were  also  hazy.  In  his  practice  he 
abjured  bleeding,  and  advocated  instead  abstinence  and  exercise. 
He  inculcated  regimen  and  diet,  and  approved  of  topical  applica- 
tions. He  was  a  daring  surgeon,  and  did  not  hesitate  to  expose 
the  liver  in  order  to  get  at  the  seat  of  hepatic  disease. 

So  much  for  the  pioneers  in  Medicine  among  the  Greeks.  I 
have  now  to  turn  shortly  to  the  pioneers  among  the  Eomans  prior 
to  the  fall  of  the  Empire.  The  Eomans,  a  hardy,  energetic  people, 
for  the  first  500  years  of  their  existence  seem  to  have  had  no 
physicians. 

About  187  B.C.,  however,  they  were  invaded  by  an  epidemic 
which  necessitated  their  employing  physicians  from  other  countries. 
They  applied  to  the  temple  of  ^sculapius  in  Epidaurum,  a  city  of 
Agria  in  the  Peloponnesus,  and,  having  obtained  one  of  the  sacred 
serpents,  founded  a  temple  of  their  own  to  ^sculapius  on  an 
island  at  the  mouth  of  the  Tiber.  They  erected  soon  after  a  second 
temple  to  the  goddess  Hygeia,  a  daughter  of  ^sculapius,  worshipped 
by  the  Greeks  as  the  goddess  of  Health.  They  subsequently  de- 
vised medical  divinities  of  their  own,  and  reared  temples  and  altars 
to  them.  Thus  they  created  the  goddess  Febris,  who  determined 
the  duration  of  fevers ;  the  goddess  Ossipaga,  who  directed  the 
growth  of  the  bones ;  the  goddess  Carna,  who  presided  over  the 
viscera  ;  the  goddess  Mephitis,  and  so  on. 

Medicine  among  the  early  Eomans  was  practised  by  slaves  and 
freedmen,  and  these  were  designated  medici  or  physicians.  The 
first  surgeon  who  established  himself  at  Eome  was,  as  Pliny  informs 
us,  named  Archagathus,  most  probably  a  Greek.  On  him  the  senate 
conferred  the  freedom  of  the  city,  and  even  supplied  him  with 
consulting  rooms  at  the  public  expense.  He  was  remarkable 
only  for  the  cruelty  of  his  operations,  and  was  ultimately  banished 
from  the  city. 

In  the  reign  of  the  Emperor  Trajan,  Heliodorus  and  Antyllus 
made  considerable  progress  in  Surgery;  the  former  contributing 
important  practical  observations  on  diseases  of  the  bones  and 
injuries  to  the  head ;  the  latter  being  the  first  to  extract  cataract 
and  perform  broncotomy. 

Antyllus  operated  in  cases  of  femoral  hernia,  and  gave  par- 
ticular instructions  as  to  the  vessels  which  should  be  selected  in 
bleeding. 


S88  PKOFKSSOU   PETTIGIIEW'S    HAKVPHAN    OKATIOX.  [maY 

Leoiiidas,  another  surgeon  of  note,  operated  in  cases  of  fistula 
(pretty  much  as  we  do  at  present),  removed  cancerous  mammae  by- 
incisions  and  cautery,  and  discoursed  with  learning  and  judgment 
on  inflammation  of  the  scrotum,  hydrocele,  hernia,  glandular  swell- 
ings, ulcers,  warts,  etc. 

Rufus,  a  skilful  physician,  who  flourished  between  the  years  117 
and  96  B.C.,  devoted  much  of  his  time  to  anatomical  pursuits, 
especially  comparative  anatomy.  He  traced  the  courses  of  several 
nerves  from  the  brain  throughout  the  body,  and  distinguished 
between  nerves  of  sensation  and  nerves  of  voluntary  motion.  He 
demonstrated  the  decussation  of  the  optic  nerves  at  the  infun- 
dibulum,  and  regarded  the  heart  as  the  organ  of  pulsation  and  the 
seat  of  life.  From  what  has  been  stated,  it  will  be  perceived  that 
no  less  than  three  anatomists  (viz.,  Herophilus,  Erasistratus,  and 
Eufus)  distinguished  between  the  nerves  of  sensation  and  motion. 

After  Eufus  came  Marinus,  whose  writings  Galen  epitomized, 
and  to  whom  he  was  greatly  indebted.  Marinus  wrote  a  treatise 
on  the  Anatomy  of  the  Muscles,  paid  great  attention  to  the  absor- 
bent system,  and  discovered  the  mesenteric  glands.  He  divided 
the  nerves  into  seven  pairs,  of  which  the  par  vagura  was  the  sixth 
pair. 

While  anatomy  was  making  slow  but  sure  progress,  botany, 
materia  medica,  and  pharmacy  were  not  neglected, — Dioscorides, 
of  Anazarba,  devoting  a  treatise  to  them,  which  was  held  in  high 
estimation. 

The  prince  of  Eoman  medical  writers  was  Aurelius  Cornelius 
Celsus,  who  flourished  in  the  first  century  a.d.  He  has  been 
aptly  designated  the  Latin  Hippocrates.  Celsus  was  more  an 
author  and  practitioner  than  an  original  investigator.  He, 
however,  wrote  a  work  on  the  human  skeleton,  in  which  he 
describes  with  remarkable  accuracy  the  shape,  position,  and 
connexion  of  the  several  bones.  Like  the  medical  priesthood,  he 
attributed  disease  to  the  anger  of  the  gods.  He  was  the  first  to 
recommend  immersion  in  hydrophobia,  and  commended  the  prac- 
tice of  the  Psylli  in  sucking  poisoned  wounds.  He  did  not  believe 
in  the  critical  days  of  disease  first  indicated  by  Hippocrates,  but 
he  dieted,  purged,  bled,  cupped,  scarified,  established  issues,  applied 
the  actual  cautery,  etc.  He  maintained  that  it  was  more  difficult 
to  cure  a  rich  than  a  poor  patient,  from  the  indulgences  of  the 
former.  He  endeavoured  to  regulate  the  bowels  by  dieting,  and 
observed  the  quantity  and  quality  of  the  urine  in  each  case. 
Curiously  enough,  he  did  not  attach  much  importance  to  the 
condition  of  the  pulse,  and  gave  it  as  his  opinion  that  the  state  of 
the  pulse  was  apt  to  deceive  the  physician.  In  his  seventh  book 
he  gives  an  interesting  piece  of  information  regarding  lithotomy. 
This  operation,  according  to  him,  was  first  performed  by  a  Greek 
physician  named  Ammonius,  who  was,  from  this  circumstance, 
afterwards  designated  Xidorofxos,  or  the  lithotomist. 


1889.]  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  989 

Aristaeus,  who  followed  Celsus,  practised  as  a  physician  at  Eome 
about  the  middle  of  the  first  century  a.d.  He  acquired  much 
reputation  by  his  inquiries  concerning  diet  and  his  investigations 
regarding  atmospheric  influences, — the  latter  investigations  induc- 
ing him  to  extend  the  theory  of  pre-existent  germs.  He  was  the 
first  to  cultivate  and  inaugurate  the  study  of  pathology. 

Aristaeus  was  succeeded  by  Aretoeus,  who  is  supposed  to  have 
flourished  during  the  reign  of  Nero.  He  regarded  the  heart  as 
the  fount  of  life  and  the  seat  of  the  soul,  and  maintained  that  this 
viscus  was  the  cause  of  the  respiration.  Further,  that  the  nerves 
were  the  organs  of  sensation  and  the  source  of  all  the  movements 
of  the  limbs.  He  considered  tetanus  as  a  disease  of  the  nervous 
system.  Epilepsy,  he  tells  us,  was  traced  by  the  ancients  to  solar 
influences,  the  Deity  of  the  sun  inflicting  it  on  wicked  people.  It 
came  in  this  way  to  be  known  as  the  sacred  disease,  and  was 
regarded  with  superstitious  awe. 

Aretceus  was  the  first  medical  author  who  directed  attention  to 
the  influence  which  the  mind  exerts  on  the  health  of  the  body, 
and  the  manner  in  which  the  body  reacts  upon  the  mind.  He 
illustrated  in  his  writings  and  practice  the  Latin  adage,  "  sit  mens 
Sana  in  corpore  sano." 

The  next  great  name  in  Medicine  is  that  of  Claudius  Galen. 
Galen,  born  at  Pergamos  in  Asia,  studied  medicine  at  Alexandria, 
the  foremost  medical  school  of  the  ancient  world.  He  travelled 
largely,  and  became  celebrated  as  an  author,  teacher,  and  practi- 
tioner in  the  reign  of  Adrian,  about  the  year  130  a.d.  He  was  a 
great  reformer  in  Medicine,  and  did  much  to  purge  the  text  of 
Hippocrates,  which  had  been  corrupted  by  incompetent  and  care- 
less commentators.  While  a  great  admirer,  he  was  not  a  slavish 
follower  of  Hippocrates.  Like  Hippocrates,  he  believed  in  the. 
power  of  Nature.  Medicine,  according  to  Galen,  is  "  an  art  which 
teaches  the  preservation  of  health  and  the  cure  of  disease."  Three 
things  in  his  opinion  constitute  the  object  of  Medicine,  viz.,  the 
body,  the  signs  of  disease,  and  the  cause  of  disease.  He  speaks  of, 
the  body  as  sound,  partly  sound,  or  unsound,  and  explains  the 
nature  of  idiosyncrasies.  He  agreed  with  Hippocrates  as  to  the 
existence  of  four  humours :  the  blood,  the  phlegm,  the  yellow  and 
the  black  bile.  He  also  acknowledged  three  kinds  of  spirits,  viz., 
the  vital,  the  natural,  and  the  animal.  The  vital  he  located  in  the 
heart,  the  natural  in  the  liver,  and  the  animal  in  the  brain.  The 
vital,  according  to  him,  distributed  heat  to  the  body  by  the  arteries  ; 
the  natural  presided  over  generation,  growth,  and  nutrition ;  and 
the  animal,  which  he  regarded  as  the  noblest,  in  conjunction  with 
the  reasoning  faculty,  presided  over  motion  and  sensation  in  every 
part  of  the  body  by  means  of  the  nerves.  He  arranged  diseases 
into  three  principal  groups :  the  first  including  those  of  similar, 
and  the  second  those  of  organic  parts,  the  third  embracing  those, 
common  to   both.     The  causes   of  disease   he   divided  into  the 


990  PROFESSOR   PETIIGREW'S   UAUVEIAN   ORATION.  [MAY 

external  and  internal,  and,  like  Hippocrates,  he  speaks  of  acute 
and  chronic  cases.  He  is  more  artificial  than  Hippocrates,  and 
loses  himself  occasionally  in  fine  drawn  distinctions.  He  refers 
incidentally  to  two  cases  of  diabetes  which  occurred  in  his  prac- 
tice, this  being  among  the  ancients  a  rare  complaint. 

Galen  did  much  to  improve  the  condition  of  anatomy  and  physio- 
logy, and  lost  no  opportunity  of  extending  his  knowledge  of  these 
important  subjects.  He  regarded  comparative  anatomy  as  the 
handmaiden  of  human  anatomy,  and  worked  at  the  two  so  success- 
fully as  to  earn  the  praise  of  Vesalius,  the  most  celebrated  of  the 
anatomists  of  the  sixteenth  century.  Galen's  chief  anatomical 
works  are  his  Anatomical  Administrations  and  the  Uses  of  the 
Farts  of  the  Human  Body.  Galen  added  considerably  to  our 
knowledge  of  the  circulation  and  the  respiration  cliiefly  through 
his  dissections  of  the  lower  animals.  To  this  astute  and  learned 
man  the  heart  was  the  most  important  organ  in  the  body, — the 
source  of  heat,  the  fount  of  the  blood,  which,  replete  with  vital 
spirits,  actuated  the  whole  body.  He  regarded  the  heart  as  a  lamp 
placed  in  the  centre  of  the  body,  the  blood  being  the  oil  which 
feeds  the  flame,  and  the  inbreathed  air  that  which  keeps  the 
flame  burning.  Respiration  in  Galen's  eyes  kept  the  flame  of  the 
heart  alive  and  engendered  the  vital  spirit — the  function  of  the 
lungs  not  being,  as  Erasistratus  thought,  to  fill  the  arteries  with  air 
in  substance.^ 

Galen  considered  the  heart  as  muscular,  and  composed  of  longi- 
tudinal and  transverse  fibres,  these  by  their  action  alternately 
shortening  and  narrowing,  and  elongating  and  widening  the  viscus 
to  produce  the  systole  and  diastole.  He  also  carefully  described 
the  valvular  apparatus  of  the  heart,  and  fully  appreciated  the 
manner  in  which  the  valves  worked,  these  being,  in  his  opinion, 
not  quite  competent.  He  was  aware  that  the  different  parts  of  the 
heart  (auricles  and  ventricles)  opened  and  closed  rhythmically,  and 
regarded  the  diastole  or  dilatation  of  the  heart  as  more  important 
than  its  systole  or  contraction.  He,  curiously  enough,  did  not 
regard  the  propulsion  of  the  blood  as  the  chief  function  of  the 
heart — misled,  no  doubt,  by  the  prevailing  belief  that  the  vascular 
system  also  contained  vital  spirit,  which  largely  consisted  of  air. 
That  he  knew  the  arteries  contained  blood  is  evident,  for  he  speaks 
of  the  arterial  blood  as  being  thinner,  purer,  and  more  vaporous 
than  that  of  the  veins — a  circumstance  which  he  thought  might 
account  for  a  certain  part  of  it  escaping  through  the  cardiac  valves. 
He  speaks  of  the  arteries  as  sucking  in  from  all  parts,  and,  by 
their  contractions,  redistributing  to  all  parts, — the  contraction  of 
the  arteries  producing  the  pulse.  He  adds,  "  All  are  agreed  that 
one  of  the  ventricles  is  the  instrument  of  alimentation,  the  other 
the  instrument  of  the  vital  spirit, — the  former  being  characterized 
by  anatomists  as  the  sanguineous,  the  latter  as  the  spiritous  ven- 
*  Lib.  de  Utilitate  Respirationis. 


1889.]  PKOFESSOll   PETTIGREW'S   HARVEIAN   ORATION.  991 

tricle.  That  the  ventricles  pulsate  at  the  same  moment  may  be 
seen  by  laying  open  the  chest  of  a  living  animal ;  but  they  do  not 
contain  blood  and  spirit  in  the  same  proportion,  the  right  having  a 
much  larger  charge  of  blood  relatively  to  its  charge  of  spirit  than 
the  left,  which  may  be  said  to  contain  the  substance  of  the 
spirit." 

Notwithstanding  what  is  here  stated,  G-alen  maintained  that  the 
arteries  contained  blood.  Thus  he  remarks,  when  an  artery  is 
divided  or  wounded  in  the  living  animal,  "We  always  see  blood 
escape.  Spirit  does  not  escape  as  a  prelude  to  the  flow  of  blood, 
from  which  we  conclude  that  the  vessel  never  contained  ought  but 
blood.^  Again,  "  If  we  lay  bare  an  artery,  include  a  portion  of  it 
between  ligatures,  and  then  open  it,  we  shall  find  it  full  of  blood." 
Not  only  was  Galen  aware  that  there  were  two  distinct  kinds  of 
vessels  (arteries  and  veins),  but  he  was  also  aware  that  the  branches 
of  each  communicated.  Thus  he  observes,  "Let  us,  therefore, 
admire  the  providence  of  Nature  which  ordains  a  twofold  order 
of  vessels,  but  arranges  mutual  openings  between  the  terminations 
of  neighbouring  branches  of  each."  The  proofs  he  gave  of  this 
arrangement  were  from  experiment  and  conclusive.  He  says,  "  If  a 
large  artery  be  divided,  both  arteries  and  veins  are  alike,  and 
rapidly  drained  of  their  blood."  Further,  "  If  you  kill  an  animal 
by  dividing  one  or  more  of  the  larger  arteries,  you  will  find  the 
veins,  as  well  as  the  arteries  of  the  whole  body,  emptied  of  their 
blood ;  but  this  could  not  happen  did  not  the  two  orders  of  vessels 
inosculate."  ^ 

Galen  does  not  seem  to  have  had  any  idea  of  the  circulation  in 
the  lungs,  for  he  speaks  of  the  blood  in  the  right  side  of  the  heart 
as  passing  through  pores  in  the  septum  ventriculorum  to  the  left 
side.  His  words  are : — "  As  air  is  drawn  into  the  lungs  by  the 
expansion  of  the  chest  in  breathing,  is  the  fine  part  of  the 
blood  attracted  from  the  right  to  the  left  ventricle  of  the  heart 
by  its  diastole,  the  partition  between  them  having  certain 
minute  pores  or  orifices  to  this  end  designed."  Galen,  however, 
was  aware  of  other  apertures  in  the  heart  in  addition  to  the  pores 
in  the  septum  ventriculorum,  for  he  observes, — "  Besides  these 
pores,  there  are  two  mouths  {duo  era)  in  the  right  ventricle — one 
hy  which  the  blood  is  brought  into  the  heart,  another  by  which 
it  is  sent  to  the  lungs."'  He  also  explains  that  all  the  blood  sent 
to  the  heart  and  the  lungs  is  not  required  for  their  nourishment, 
and  concludes, — "  It  is  therefore  manifest  that  it  must  be  trans- 
mitted to  the  left  sinus  of  the  heart,"  but  in  what  way  he  does  not 
state. 

Galen  thought  that  the  blood  of  the  pulmonary  artery  went 
mainly  to  nourish  the  lungs,  a  certain  portion  of  it  only  reaching 

^  Lib.  an  Sanguis  in  Arteriis  naturd  contineatur, 
2  De  Natura  Facult.,  iii.  15. 
'  Ibid.,  lib.  i.  cap.  7. 


992  PKOFESWOli   rETTIGKEW's   IIAUVEIAN   ORATION.  [mAY 

the  pulmonaiy  vein  by  the  anastomoses  existing  between  the 
pulmonary  artery  and  pulmonary  vein.  He  did  not  believe,  and 
does  not  state  that  the  blood  passes  hudily  or  in  mass  from  the 
pulmonary  artery  to  the  pulmonary  vein.  He  inclined  to  the 
belief  that  the  function  of  the  lungs  was  to  cool  the  heart,  and 
remarks, — "  Many,  therefore,  and  among  them  some  of  the  most 
able,  both  of  our  philosophers  and  physicians,  have  seen  that  the 
heart  requires,  not  air  in  substance,  but  coolness  only,  whereby  it 
is  refreshed,  and  this  is  the  purpose  of  respiration."  While 
attaching  the  highest  importance  to  the  heart,  the  liver,  according 
to  Galen,  is,  in  some  respects,  entitled  to  precedence,  as  being  the 
laboratory  of  the  blood  {est  sanguificatione  dicatum)  and  source  of 
the  streams  which  nourish  the  body. 

Galen  may  be  said  to  have  been  the  dictator  in  Medicine  for  up- 
wards of  thirteen  centuries.  Nothing  is  more  remarkable  about 
this  truly  great  man  than  his  conceptions  of  God  and  religion. 
Eeferring  to  his  works,  he  says, — "  In  writing  these  books  I  compose 
a  true  and  real  hymn  to  that  awful  Being  who  made  us  all ;  and,  in 
my  opinion,  true  religion  consists  not  so  much  in  costly  sacrifices 
and  fragrant  perfumes  offered  upon  His  altars,  as  in  a  thorough 
conviction  impressed  upon  our  own  minds,  and  an  endeavour  to 
produce  a  similar  impression  upon  the  minds  of  others,  of  His 
unerring  wisdom.  His  resistless  power,  and  His  all-diffusive  good- 
ness. For  His  having  arranged  everything  in  that  order  and  dis- 
position which  are  best  calculated  for  its  preservation  and  con- 
tinuation, and  His  having  condescended  to  distribute  His  favours  to 
all  His  works,  is  a  manifest  proof  of  His  goodness  which  calls 
loudly  for  our  hymns  and  praises.  His  having  found  the  means 
necessary  for  the  establishment  and  preservation  of  this  beautiful 
order  and  disposition  is  as  incontestable  a  proof  of  His  wisdom  as 
His  having  done  whatever  He  pleased  is  of  His  omnipotence."  This, 
from  one  groping  in  the  dark  and  overshadowed  by  temples  to 
unknown  gods,  is  truly  sublime. 

After  the  days  of  Galen  Medicine  underwent  a  dreary  and 
partial  eclipse  for  many  centuries,  comparatively  few  men  of  mark 
anywhere  appearing.  Among  the  few  may  be  mentioned  Nemesius, 
Bishop  of  Emessa,  a  city  of  Phoenicia,  who  flourished  at  the  close 
of  the  third  century,  and  whom  some  erroneously  believe  to  have 
forestalled  Harvey  in  the  discovery  of  the  circulation.  The 
bishop's  own  words  dispose  of  his  pretensions.  He  says,  "  The 
motion  of  the  pulse  originates  in  the  heart  and  principally  from 
the  left  ventricle,  the  artery  being  violently  dilated  and  contracted 
with  unvarying  regularity.  During  its  dilatation  it  draws  the 
thinner  part  of  the  blood  from  the  next  veins,  the  exhalations  or 
vapours  of  which  blood  form  the  aliment  for  the  vital  spirit ;  but, 
during  its  contraction,  it  exhales  whatever  vapours  it  has  by  secret 
passages  through  the  whole .  body,  so  that  the  heart  throws  out 
whatever  is  fuliginous  through  the  mouth  and  nose  by  expiration." 


1880]  PROFESSOR  PETTIGREW'S  HARVEIAN  ORATION.  993 

In  addition  to  what  is  here  stated,  it  is  only  necessary  to  observe 
that  Neraesius,  in  common  with  Hippocrates,  Erasistratus,  Galen, 
and  all  those  who  preceded  him,  believed  that  the  sole  use  of  the 
arteries  was  to  transmit  the  vital  spirits. 

Oribasius,  who  lived  in  the  fourth  century  (351  A.D.),  also 
deserves  a  passing  word.  This  physician  and  author  was  strong 
in  scarification  in  amenorrhoea,  dyspnoea,  cephalalgia,  and  affec- 
tions of  the  eyes.  He  also  directed  attention  to  a  form  of  mad- 
ness allied  to,  if  not  identical  with,  our  melancholia. 

The  future  of  medicine,  as  indeed  of  everything  else,  was  power- 
fully influenced  by  the  fall  of  the  great  Eoman  Empire  towards 
the  close  of  the  fifth  century. 

^tius,  who  flourished  in  the  sixth  century,  was  the  first  to  give 
an  account  of  the  guinea  worm.  He  was  great  in  the  cure  of  gout, 
and  indulged  occasionally  in  a  little  quackery  in  the  form  of 
relics,  spells,  and  incantations.  He  was  followed  by  Palladius, 
who  wrote  a  book  on  fevers. 

The  sixth  century  was  remarkable  for  the  introduction  of  three 
unmixed  evils,  viz.,  Mahomet,  the  false  prophet,  small-pox,  and  the 
measles.  Small-pox  and  measles  are  believed  to  have  first  made 
their  appearance  in  Arabia,  the  former  being  carefully  described 
by  Aaron,  a  native  of  Alexandria,  about  the  beginning  of  the 
seventh  century.  According  to  the  Chinese,  small-pox  had  a  very 
remote  origin,  viz.,  1212  B.C. 

In  the  seventh  century  appeared  Paulus,  the  first  of  the  ancients 
to  publish  a  treatise  on  midwifery.  He  has,  from  this  circumstance, 
been  called  Paulus  Obstetricius.  Paulus,  in  addition  to  being  a 
famous  accoucheur,  was  a  courageous  and  skilled  surgeon,  and 
devised  many  new  operations.  He  writes  learnedly  on  hernia  and 
bronchotomy. 

A  century  after  Paulus  came  Theophilus,  who  was  the  first  to 
descant  learnedly  on  the  urine. 

In  the  seventh  century  (640  a.d.)  Alexandria  was  captured  by 
the  restless  and  resistless  Arabs,  impelled  by  their  infatuated 
leaders  and  new  religion.  This  momentous  event  put  the  Arabs 
in  possession  of  the  magnificent  Alexandrian  libraries,  and  the  rich 
treasures  of  Greek  and  Koman  medical  literature  which  they  con- 
tained. This,  with  the  incursions  of  the  Vandals,  hastened  the 
decline  of  learning  in  the  West,  and  transferred  not  only  the 
books,  but  also  the  philosophers  of  Europe  to  the  shores  of  Asia. 
Medical  science  and  literature  for  a  time  forsook  Greece,  Italy,  and 
other  old  centres,  and  took  up  their  abode  with  the  Saracens,  who 
occupied  themselves  chiefly  in  translating  the  Greek  and  Koman 
authors,  particularly  the  former.  In  many  instances  they  also 
copiously  interlarded  them  with  commentary. 

Of  those  who  taught,  practised,  and  wrote  on  Medicine  among 
the  Arabs  at  this  period  may  be  mentioned  Mahomet,  the  author 
of  Medical  Aphorisms;  Theodunus  and  Theodocus,  both  eminent 

EDINBURGH   MED.    JODRN.,   VOL.    XXXIV. — NO.   XI.  6  K 


994  PROFESSOR  PETTIGREW'S   IIARVEIAN   ORATION.  [MAY 

teachers  of  medicine;  Elkenanus,  Aaron,  Serapion,  Rhazes, 
Avicenna,  Haly  Abbas,  Abdalatif,  etc. 

Rhazes  was  the  first  writer  who  expressly  treated  of  the  diseases 
of  childhood,  and  Haly  Abbas  has  given  us  the  oldest  and  fullest 
account  of  the  state  of  Medicine  among  the  Arabs. 

In  the  eighth  century  (744  a.d.)  the  Arabs  spread  westward  to 
Spain,  and  Medicine  in  this  way  came  to  be  fostered  and  developed 
among  the  Moors. 

Aldalrhamson  in  this  century  founded  the  city  and  university 
of  Cordova,  the  latter  being  the  most  celebrated  seat  of  learning  at 
the  time.  Its  library  in  the  tenth  century  contained  no  less  than 
250,000  volumes.  In  the  twelfth  century  Spain  could  boast  of 
seventy  public  libraries ;  academies  being  founded  at  Seville, 
Toledo,  and  Murcia,  At  all  these  seats  of  learning  lived  numerous 
writers  of  distinction,  medical  and  otherwise. 

Avenzoar,  an  Arabian  author,  born  at  Seville,  flourished  towards 
the  end  of  the  eleventh  century,  and  acquired  a  great  reputation 
as  a  physician,  surgeon,  and  pharmacist.  He  treats  of  hydroperi- 
cardium  and  obstruction  of  the  oesophagus,  recommending,  in  the 
latter  case,  the  insertion  of  a  silver  or  tin  tube  into  the  gullet  to 
admit  of  the  passage  of  food  into  the  stomach,  and,  when  this  fails, 
nutrient  enemata  or  the  immersion  of  the  body  in  nutrient  broth 
to  be  absorbed  by  the  skin.  He  explained  how  fracture  of  the 
innominate  bone,  wounds  in  the  arteries  and  veins,  gangrene  of 
the  intestine,  etc.,  were  to  be  treated,  and  his  book  on  pharma- 
ceutical preparations  abounds  in  simple  and  compound  medicines, 
in  poisons  and  their  antidotes,  and  other  important  and  useful 
information.     He  also  wrote  a  treatise  On  Medicine  and  Diet. 

At  the  end  of  the  thirteenth,  or  early  in  the  fourteenth  century, 
Albucasis  came  to  the  front.  He  was  the  first  to  employ  cold  in 
the  treatment  of  small-pox,  a  form  of  treatment  revived  by  Dr 
Currie  in  recent  times.  He  is  the  only  author  among  the  ancients 
who  has  supplied  us  with  drawings  of  the  several  instruments 
employed  in  surgery  in  his  day.  Cautery  and  caustic  potass,  he 
informs  us,  were  greatly  in  vogue  among  the  Arabs,  and  hence  the 
Greeks  speak  of  the  practice  as  Kava-iq  Apa^iKtj,  or  Arabian 
burning.  In  fact,  the  Arabs  of  the  desert,  as  well  as  the  ancient 
Egyptians,  placed  the  greatest  reliance  on  burning  in  treating  deep- 
seated  pains  and  chronic  intractable  complaints. 

Albucasis  was  in  some  respects  a  great  surgeon.  In  his  second 
book  he  describes  no  fewer  than  ninety-six  operations  performed 
with  the  knife.  Among  these  may  be  mentioned  the  opening  of 
the  head  in  hydrocephalus,  excision  of  the  tonsils,  extirpation  of 
the  uvula,  the  removal  of  the  thyroid  gland  in  goitre,  the  treatment 
of  tumours  by  the  knife  and  leaden  ligature,  the  operation  for 
dropsy,  the  treatment  of  arrow  wounds,  lithotomy  in  the  male  and 
female,  etc.,  etc. 

With  these  remarks  the  history  of  medicine  among  the  Arabs 


1880.]  PROFESSOR  PETTIGREW'S   HAUVEIAN   ORATION.  995 

and  Moors  up  till  the  fourteenth  century  may  be  brought  to  a 
close.  It  only  remains  to  be  stated  that  the  Arabs  and  Moors 
devoted  themselves  very  sedulously  to  the  cultivation  of  chemistry 
and  pharmacy,  in  which  they  greatly  excelled,  and  in  both  of  which 
they  introduced  many  important  improvements. 

While  medicine  was  progressing  in  Arabia  and  Spain  it  was 
developing,  although  less  satisfactorily,  among  the  later  Greeks, 
The  G-reeks  of  the  middle  period  deserving  of  notice  are  Actuarius, 
Nonus,  Psellus,  Simeon,  and  Demetrius  Pepagomenus. 

It  should  be  stated  that  in  the  tenth  century  the  great  school 
of  Salernum,  in  the  territory  of  Naples,  was  founded.  This  cele- 
brated university  flourished  with  ever  increasing  splendour  for 
upwards  of  three  centuries.  One  of  its  earliest  and  most  distin- 
guished pupils  was  Constantine  the  African,  so  called  from  his  having 
been  born  at  Carthage  about  the  year  1010  a.d.  He  it  was  who  first 
introduced  the  Greek  and  Arabian  systems  of  medicine  into  Italy. 
He  was  one  of  the  earliest  writers  on  diseases  of  the  stomach. 

Towards  the  end  of  the  tenth  century  medicine  fell  more  or  less 
into  the  hands  of  the  Jews,  who  practised  not  only  on  their  own 
people,  but  also  on  the  Moors  and  Christians.  They  were  especi- 
ally in  the  employment  of  higher  personages — princes,  kings, 
emperors,  and  even  the  popes. 

From  tlie  tenth  to  the  fourteenth  century  medicine  suffered 
sorely  at  the  hands  of  the  clerics,  ignorant  priests  usurping  the 
places  of  learned  physicians.  So  crying  had  this  evil  become  in 
the  tw^elfth  century,  that  the  first  Lateran  Council  under  the 
pontificate  of  Calistus  II.  was  appointed  to  deal  with  it  in 
1123  A.D.  This  council  peremptorily  forbad  the  regular  clergy 
to  officiate  at  the  bedside  in  any  other  capacity  than  that  of 
ministers  of  the  gospel.  Other  restrictions  in  the  same  direction 
were  imposed  at  the  Council  of  Kheims  in  1131  a.d.,  and  at  the 
second  Lateran  Council  in  1139  a.d.  So  hardened,  however,  were 
the  priests  and  monks  in  their  iniquitous  practices  that  the  fulmi- 
nations  of  the  Vatican  were  disregarded,  particularly  on  the  Con- 
tinent. 

In  Britain  a  higher  tone  of  morality  fortunately  prevailed,  and 
Alcuinus,  an  abbot  of  Canterbury,  having  been  despatched  by  Oifa, 
king  of  Mercia,  on  a  mission  to  the  court  of  the  Emperor  Char- 
lemagne, this  potentate  retained  Alcuinus  as  his  tutor  in  science. 
The  abbot  became  a  favourite  with  the  Emperor,  and  to  his  influ- 
ence the  famous  University  of  Paris  owes  its  origin.  He  was  also 
the  means  of  establishing  similar  institutions  in  the  leading  towns 
both  in  France  and  Italy. 

From  the  tenth  to  the  sixteenth  century  much  valuable  time 
was  wasted  in  fruitless  attempts  to  discover  the  philosopher's  stone, 
which  was  to  convert  all  the  baser  metals  into  gold,  and  the  elixir 
vitse,  which  was  to  confer  on  humanity  perennial  youth.  These 
ignes  fatui  were  attended  with  one  good  result.     They  directed 


996  PROFESSOR   PETTIGltEW'S   HARVEIAN    ORATION.  [MAY 

men's  minds  to  the  importance  of  chemistry,  known  in  those  early 
days  as  alchemy. 

Among  the  most  noted  of  the  chemists  may  be  mentioned 
Albertus  Magnus,  Eoger  Bacon,  and  Arnaud, — the  first  flourishing 
in  Germany,  the  second  in  England,  and  the  third  in  France. 
Albertus  Magnus  was  born  towards  the  close  of  the  twelfth  century, 
Roger  Bacon  in  1214  a.d.,  and  Arnaud  in  1250  a.d.  Prior  to  their 
day  chemistry  was  confined  almost  wholly  to  the  Arabians  inhabit- 
ing Asia,  Africa,  and  Spain. 

In  the  year  1276  a.d.  Mundinus,  the  anatomist,  was  born.  He 
did  much  to  clear  up  the  anatomy  of  the  uterus,  and  showed  t?iat 
the  ureters  entered  the  bladder  obliquely,  an  arrangement  which 
prevents  the  urine  from  flowing  back  into  the  kidneys.  His 
account  of  the  heart  and  its  valves  is  also  wonderfully  accurate 
and  clear.  He  designated  the  valves  ostiola,  or  little  doors,  but 
his  knowledge  of  the  circulation  did  not  exceed  that  of  his  pre- 
decessors. 

Medical  science  was  slow  to  take  root  in  England.  It  can 
scarcely  be  said  to  have  been  cultivated  there  before  the  thirteenth 
century.  This  was  due  to  two  circumstances — first,  Medicine  in 
England  during  the  thirteenth  century  was  largely  in  the  hands 
of  the  monks ;  and,  second,  it  was  not  encouraged  in  any  of  the 
English  colleges  or  universities. 

Gilbert  Anglicanus  may  be  regarded  as  the  first  English  writer 
on  Medicine.  Gilbert  speaks  of  scrofulous  glands  as  the  king's 
evil,  from  a  common  belief  that  the  royal  touch  was  sufficient  to 
cure  the  malady. 

John  of  Gaddesden,  the  author  of  Bosa  Anglica,  came  next. 
He  flourished  about  the  year  1320  a.d.,  and  was  great  in  secret 
nostrums.  He  tells  us  that  the  surgeon  barbers  gave  him  a  long 
price  for  a  prescription  into  the  composition  of  which  tree  frogs 
entered.  He  rose  to  distinction  and  wealth,  and  was  the  first  of 
the  English  Court  physicians. 

Balescon,  born  about  the  year  1361  a.d.,  advocated  the  extirpa- 
tion of  cancer  by  the  aid  of  arsenical  applications,  a  form  of  treat- 
ment revived  in  modern  times  by  Plunkett  and  others. 

In  1440  A.D.  the  art  of  printing  was  discovered,  and  gave  a 
tremendous  impetus  to  every  form  of  learning,  medical  learning 
included. 

In  1487  A.D.  Jacques  du  Bois  Sylvius  of  Amiens  was  born. 
He  devoted  his  time  and  talents  to  anatomy,  and  divided  the 
muscles  into  those  of  automatic  life  and  those  under  the  control  of 
the  will.  The  former  included  the  heart,  stomach,  and  urinary 
bladder,  their  fibres  being  arranged  in  layers  running  longitudin- 
ally, transversely,  and  obliquely.  In  the  heart,  in  his  opinion,  the 
contraction  of  the  longitudinal  fibres  produced  the  diastole,  the 
contraction  of  the  transverse  fibres  producing  the  systole. 

Sylvius  was  acquainted  not  only  with  the  valves  of  the  heart, 


1880.]  PUOFESSOU   PETTIGREW's   HARVEIAN    ORATION.  997 

but  also  with  the  valves  of  the  veins.  He  was  also  aware  of  the 
existence  of  the  foramen  ovale  in  the  fcetal  heart.  Speaking  of 
tlie  valves,  he  says,  "  There  is  a  membranous  process  of  a  similar 
kind  at  the  commencement  of  the  vena  azygos  and  others  also  in 
more  than  one  of  the  great  vessels,  such  as  the  jugulars,  brachials, 
crural  veins,  and  trunk  of  the  cava  as  it  leaves  the  liver.  The  use 
of  all  these  processes  is  the  same  as  that  of  the  membranes  which 
close  the  orifices  of  the  heart.  Some  of  the  membranes  (valves)  in 
question  have  even  delicate  layers  of  muscular  fibres  like  those  of 
the  larger  veins  and  arteries,  the  oesophagus,  urinary  bladder," 
etc. 

Sylvius  invented  the  art  of  injecting,  in  tracing  the  bloodvessels, 
and  the  obstruction  experienced  by  his  injected  material  in  passing 
the  venous  valves  of  necessity  directed  his  attention  to  them. 
Sylvius  anticipated  Fabricius  in  his  knowledge  of  the  venous 
valves,  and  the  marvel  is  that  with  his  injecting  apparatus,  which 
enabled  him  to  fill  the  vessels  with  a  foreign  substance,  and  the 
course  of  which  could  be  traced,  he  did  not  discover  the  circula- 
tion. He,  however,  failed  to  interpret  the  true  significance  of  the 
venous  valves,  and,  misled  by  the  common  belief  that  the  venous 
blood  fed  the  tissues,  he  naturally  concluded  that  the  valves  of  the 
veins  were  mere  obstructions  for  delaying  the  blood  to  that  end. 
Had  he  injected  from  a  main  artery, — the  beginning  of  the  aorta,  for 
instance, — and  continued  the  injecting  process  long  enough,  the 
injected  material  would,  of  necessity,  have  returned  to  the  point 
from  whence  it  set  out,  and  a  demonstration  of  the  injected 
substance  in  a  circle  would  have  been  the  result. 

In  1492  A.D.  syphilis  first  made  its  appearance  in  Europe,  im- 
ported, it  is  believed,  from  the  New  World  by  the  followers  of 
Columbus.  One  of  the  earliest  authors  on  this  formidable  disease 
was  Marcellus,  who  wrote  about  1495  a.d.  The  famous  surgeon 
and  anatomist,  Jacobus  Carpus,  otherwise  called  Berengarius,  was 
one  of  the  first  to  employ  mercurial  friction  in  the  cure  of 
syphilis. 

In  the  fifteenth  century  considerable  attention  was  paid  to  the 
ingredients  and  virtues  of  mineral  waters,  and  in  this  century  also 
scarlet  fever  suddenly  broke  out  in  Italy. 

In  1503  A.D.  Bounacciolus  printed  his  Fnneas  Muliebris,  in 
which  he  gave  an  accurate  account  of  the  organs  of  generation 
and  the  foetus. 

In  1509  A.D.  Ambrose  Pare,  the  celebrated  French  surgeon,  was 
born.  He  did  good  service  for  surgery  by  his  practice  of  separat- 
ing and  drawing  out  the  bloodvessels  and  carefully  ligaturing 
them.     He  also  improved  the  treatment  of  gunshot  wounds. 

In  1516  A.D.  Achillini  published  his  fine  work  on  the  anatomy 
of  the  human  body. 

A  great  impulse  was  given  to  Medicine  in  England  in  1518  A.D. 
by  the  founding  and  endowing  of  the  College  of  Physicians  of 


998  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [MAY 

London  by  the  learned  and  liberal  Thomas  Linacre,  who  practised 
his  profession  very  successfully  in  the  reign  of  Henry  VIII.  Lin- 
acre, in  addition  to  founding  the  College  of  Physicians,  established 
two  medical  colleges  at  Oxford,  and  a  similar  number  at  Cambridge. 
In  Linacre's  time  the  Bishop  of  London  and  the  Dean  of  St  Paul's 
could  examine  and  grant  degrees  in  Medicine,  and  there  were  other 
irregularities  and  abuses  which  Linacre  was  anxious  to  correct. 
He  aimed  at  nothing  short  of  elevating  the  profession  as  a  whole, 
and  through  his  influence  at  Court  it  was  ordained,  by  charter  in 
1523  A.D.,  that  no  one  should  practise  in  London  or  the 
provinces  who  had  not  been  examined  and  licensed  by  the  new 
college. 

In  1521  A.D.  Carpus  or  Carpensis,  also  called  Berengarius,  pub- 
lished his  commentaries  on  the  anatomy  of  Mundinus,  a  work 
abounding  in  new  and  important  facts,  and  of  which  Haller 
speaks  in  the  highest  praise.  In  the  succeeding  year,  viz.,  1522 
A.D.,  he  published  his  own  Anatomy,  with  plates,  at  Bologna.  As 
professor  of  anatomy  at  Bologna,  Carpus  is  said  to  have  dissected 
100  bodies  between  the  years  1518  and  1555  a.d., — a  notable  feat, 
when  bodies  were  scarce,  and  their  dissection  encompassed  with 
difficulties. 

{To  he  continued.) 


II. -FACTS  RELATIVE  TO  MENSTRUATION. 

By  James  Oliver,  M.D.,  F.R.S.  (Edin.),  Assistant  Physician  to  the  Hospital 

for  Women,  London. 

In  every  healthy  human  female,  as  a  rule,  during  the  so-called 
child-bearing  epoch,  which  extends  on  the  average  over  a  period 
of  thirty-two  years,  the  uterus  becomes  the  seat  of  a  periodically 
recurring  functional  disturbance,  evidenced  by  the  emission  of  a 
more  or  less  marked  hajmorrhagic  discharge.  As  the  initial  estab- 
lishment and  each  subsequent  recurrence  of  this  monthly  pheno- 
menon is  frequently  accompanied  by  symptoms  of  a  general  as 
well  as  local  character,  we  shall  designate  under  the  appellation 
menstruation  the  whole  essential  train  of  events,  and  not  its 
mere  outward  manifestation.  Menstruation  is  a  crisis  of  transi- 
tion, and  as  such  changes  generally  are  full  of  pain,  it  is  not  at  all 
astonishing  that  we  should  so  frequently  find  this  phenomenon  in 
the  human  female  associated  with  more  or  less  disturbance  of  a 
constitutional  character.  The  eagle  when  it  moults  is  sickly,  and 
rids  itself  of  the  old  beak  by  dashing  it  against  a  stone. 

Normally  all  the  functional  disturbances  of  the  body  are, 
through  habituation,  performed  in  a  somewhat  automatic  manner ; 
and  although  these  changes  may  at  one  time,  in  the  evolution  of 
life,  have  excited  a  conscious  sensation,  they  are  now  wholly 
ignored  by  the  higher  centre  participating  in  feeling,  and  fail  to 


1889.]  FACTS   UELATIVE   TO   MENSTRUATION.  999 

arouse,  therefore,  any  knowledge  of  their  presence.  This  fact  is 
one  worthy  of  note,  being,  as  it  must,  the  key  to  a  correct  apprecia- 
tion and  interpretation  of  all  painful  impressions. 

Our  epiperipheral  and  visceral  sensations  may,  when  augmented, 
produce  a  sensation  of  pain.  A  gentle  warmth  applied  to  the  body 
may  prove  grateful,  yet  it  is  possible  to  so  augment  this  pleasur- 
able sensation  that  it  becomes  an  actual  pain.  All  pains,  there- 
fore, may  be  considered  as  aggravated  sensations  of  pleasure. 

In  the  case  of  the  uterine  system,  multifarious  and  apparently 
trivial  are  the  influences  at  work  which  may  serve  to  disturb  the 
healthy  evolution  of  its  functions.  The  molecular  world,  organic 
as  well  as  inorganic,  exists  in  a  perpetual  state  of  trepidation,  and 
vital  equili])ration  is  the  outcome  of  an  inherent  power  of  adapta- 
tion. Normally  the  structural  and  functional  integrity  of  the 
organism  is  maintained  by  a  mutual  dependence  of  the  organs 
upon  each  other,  and  according  to  the  manner  in  which  they  each 
and  all  respond  to  those  numerous  changes  which  from  time  to 
time  arise  in  the  environments  of  the  individual.  The  variations 
in  the  waves  of  molecular  motion  occurring  in  every  organ,  and 
associated  with  physiological  activity,  are  radiated  to  and  affect, 
however  feebly,  every  ultimate  tissue  of  the  body.  So  completely 
is  this  intercommunication  through  the  medium  of  the  nervous 
system  carried  on,  and  so  apt  are  the  different  structures  of  the 
organism  to  perform  functions  other  than  those  for  which  they 
have  become  specialized,  that  vicarious  compensation  may  be 
readily  established.  In  the  case  of  double  organs  of  the  body  it 
is  a  noteworthy  fact  with  which  every  one  is  familiar,  that  the 
removal  of  one  may  affect  but  little,  if  at  all,  the  well-being  of  the 
body  generally  ;  the  remaining  organ,  at  the  same  time,  because  of 
augmented  functional  activity,  undergoing  slight  or  even  well- 
marked  enlargement.  This  compensatory  change  will  be  mani- 
fested, not  only  by  organs  recognised  as  active,  but  also  by  such  as 
hitherto  have  been  considered  as  somewhat  obsolete.  In  many  of 
the  lower  organisms,  where  structural  differentiation  is  ill-defined, 
vicarious  function  is  readily  fulfilled.  The  animal,  for  example, 
may  be  turned  outside  in  with  impunity,  the  vital  integrity  of  the 
organism  being  still  maintained  unimpaired.  The  endoderm 
already  but  feebly  specialized,  although  set  apart  for  assimilation, 
will  perform  with  ease  the  function  of  the  ectoderm,  that  of  elimina- 
tion, whilst  the  ectoderm  in  turn  assumes  forthwith  the  power  of 
assimilation,  and  discharges  effectually  a  function  hitherto  foreign 
to  it,  and  performed  previously  by  the  inner  layer. 

Lately  I  saw  a  girl  who  had  never  evinced  the  external  mani- 
festation of  menstruation,  although  she  suffered  from  what  I  called 
a  menstrual  hsematuria,  recurring  as  this  did  every  month  in  asso- 
ciation with  marked  constitutional  disturbance.  The  uterus  was 
in  this  case  found  to  be  abortive,  and  there  could  not  be  detected 
any  vestige  of  an  external  genital  tract.     The  ovary  on  the  left 


1000  DK   JAMES   OLIVER   ON  [MAY 

side,  the  only  one  which  existed,  was  removed,  and  was  found  to 
be  somewhat  larger  than  usual,  and  apparently  functionally 
active.  When  we  recall  the  fact  that  the  kidney  and  uterus  are 
developed  from  the  same  primordial  structure,  a  case  such  as  the 
above,  anomalous  though  it  is,  does  not  astonish  us.  In  the 
animal  economy  one  sees  constantly  enunciated  the  fact  too  fre- 
quently ignored,  that  functional  activity  and  structural  integrity 
proceed  together  hand  in  hand,  and  that  they  are  regulated  by  a 
mutual  action  and  reaction  upon  each  other.  If  the  functional 
activity  of  any  organ  be  augmented,  but  not  unduly,  the  structural 
integrity  of  that  organ  will  be  maintained  and  be  rendered  more 
perfect.  That  each  organ  of  the  body  lias  a  representative  nerve 
centre,  by  which  it  is  governed  and  enabled  to  act  in  unison  with  and 
respond  to  changes  in  the  other  tissues  of  the  body,  there  can  be  no 
doubt.  It  is,  therefore,  more  than  probable  that  the  physiological 
changes  recurring  from  time  to  time  in  the  uterus  are  not  only  antici- 
pated by,but  actually  the  result  of  some  molecular  disturbance  arising 
spontaneously  in  some  centre  located  in  the  higher  part  of  the 
cerebro-spinal  tract,  possibly  somewhere  in  the  medulla  oblongata. 
The  mere  fact  that  the  functions  of  the  uterus  may  be  revealed  un- 
interruptedly after  the  spinal  cord  has  been  completely  severed  in 
the  dorsal  region  is  no  criterion,  and  cannot  justify  us  in  conclud- 
ing that  there  exists  no  representative  higher  nerve  centre.  The 
nervous  system  is  so  complete  and  its  functions  so  entangled  that 
the  human  mind  is  often  baffled  in  its  attempts  to  elucidate  and 
explain  revealed  facts.  It  is  notorious  that  the  spinal  cord  has 
been  divided  in  animals,  and  although  paraplegia  has  forthwith 
resulted,  complete  power  over  the  lower  limbs  has  been  regained 
without  union  of  the  severed  nerve  tissue  occurring.  Structural 
evolution  forces  us  to  accept  the  hypothesis  that  a  nerve  centre 
must  exist  for  the  uterus,  and  that  it  is  subjected  to  well-regulated 
periodic  discharges  so  long  as  this  centre  is  free  from  other  well- 
marked  local  and  constitutional  influences.  Like  all  other  nerve 
centres  fulfilling  a  similar  dispensation,  this  uterine  centre  is  un- 
doubtedly beyond  all  volitional  control,  but  is  nevertheless  capable 
of  being  disordered  by  emotional  impressions.  With  this  fact 
every  one  is  familiar.  A  sudden  shock  experienced  during  men- 
struation, and  apart  from  any  bodily  injury,  will  produce,  as  I  have 
frequently  noted  in  some  females,  immediate  cessation  of  the  flow, 
and  may  interrupt  for  a  more  or  less  indefinite  length  of  time 
thereafter  its  amount  and  periodic  regularity.  The  resulting  dis- 
turbance M'ill  depend  essentially  upon  the  state  of  the  nervous 
system  and  its  proneness  to  molecular  instability.  The  potent 
influence  of  fright  is  revealed  in  the  following  case,  which  recently 
came  under  my  notice : — Emily  S.,  set.  29,  and  married  five  years  ; 
has  had  no  children  and  no  miscarriages ;  began  to  menstruate  at 
the  age  of  14,  the  flow  lasting,  as  a  rule,  two  days.  At  the  age  of 
16  patient  had  a  fright,  after  which  there  was  total  cessation  of  the 


1889]  FACTS    UELATIVE   TO   MENSTRUATION.  1001 

catamenial  discharge  for  seven  years.  Six  years  ago,  i.e.,  at  the 
age  of  23,  the  flow  reappeared,  and  has  continued  to  recur  regularly 
every  month,  the  amount  being  equal  to  that  manifested  prior  to 
the  shock. 

Cases  are  on  record  in  which  a  menstrual  discharge  has  appeared 
very  early  in  life,  whilst  the  female  is  as  yet  but  a  mere  child,  and 
not  more  than  two  years  of  age.  In  spite  of  such  anomalies,  how- 
ever, a  certain  developmental  perfection  or  completion  is  requisite 
for  reproduction,  and  man  cannot  at  any  very  early  age  reproduce 
his  like.  There  are  many  factors  at  work  which  may  tend  to  de- 
termine the  early  occurrence  of  menstruation.  A  girl  with  a  san- 
guine temperament  attains  pubescence  as  a  rule  at  a  much  earlier 
period  than  does  a  girl  with  a  lymphatic  temperament.  Natural 
heat  increases,  no  doubt,  the  child-bearing  propensity.  Confine- 
ment, however,  in  close  workrooms  and  factories  causes  a  retarda- 
tion of  the  menstrual  functions,  and  may  even  after  the  establish- 
ment of  such  produce  a  decided  interruption  in  the  periodicity,  and 
induce  cessation  or  suppression  for  a  more  or  less  indefinite  length 
of  time.  In  our  everyday  life  there  are  many  agencies  perpetually 
at  work  which  threaten  to  disturb  the  nervous  equilibration  of  our 
bodies  ;  it  is,  therefore,  astounding  that  the  whole  mechanism  is 
not  more  frequently  thrown  out  of  gear. 

The  age  at  which  pubescence  is  attained,  or  rather  at  which  the 
catamenial  discharge  makes  its  appearance,  depends  greatly  upon 
climatic  as  well  as  upon  social  influences.  Throughout  the  United 
Kingdom  menstruation  is  established  about  the  age  of  14,  some- 
times earlier,  or  it  may  be  much  later.  In  hot  climates  puberty  is 
reached  at  a  much  earlier  period  than  in  cold.  In  the  physical 
world  heat  augments  vibration  ;  in  the  organic  world  a  similar 
result  obtains  :  activity  is  thereby  hastened  and  increased.  Child- 
bearing  is  generally  observed  to  begin  and  cease  at  an  earlier  age 
in  tropical  than  in  temperate  countries,  and  the  resulting  variations 
of  climate  are  the  same  for  females  apparently  of  all  races.  The 
influence  of  climate  may  and  does  eventually  become  habitual,  and 
this  even  after  the  removal  of  the  individual  from  the  location  of 
its  action.  Habit,  when  once  well  established,  is  not  readily 
interrupted. 

In  the  West  Indies  white  and  black  people  live  under  the  same 
climate ;  their  surroundings,  however,  are  not  alike.  In  spite  of 
this  there  appears  to  be  no  difference  in  respect  to  the  age  of 
puberty,  the  period  of  fecundity,  or  any  of  the  circumstances  con- 
nected with  menstruation,  as  it  occurs  in  white  and  black  women 
living  in  this  quarter  of  the  globe. 

Dr  Winterbottoin,  in  speaking  of  the  African  races,  observes  of 
the  catamenia : — "  I  am  unable  to  speak  with  precision  respecting 
this  excretion  in  the  natives  of  Africa,  but  among  the  settlers  at 
Free  Town,  in  Sierra  Leone,  my  opportunities  of  observation  were 
very  extensive.     It  may  be  proper  to  remark  that  these  people, 

EDINBURGH   MED.    JOURN.,    VOL,    XXXIV. — NO.    XI.  6  L 


1002  DR   JAMES   OLIVER   ON  [MAY 

who  are  generally  called  Nova  Scotians,  because  brought  from  that 
country  to  Sierra  Leone,  are  blacks  who  were  either  carried  to 
America  when  very  young,  or  were  born  there  of  parents  who 
came  from  Africa.  Of  course  they  are  sufficiently  acquainted  with 
the  customs  of  white  people,  and  they  live  nearly  in  the  same  way 
as  the  lower  classes  of  people  in  Europe.  Among  the  Nova 
Scotian  women  the  catamenia  have  precisely  the  same  appearance 
as  among  Europeans  who  are  usually  exposed  to  the  open  air,  and 
the  same  varieties  occur  with  regard  to  quantity,  periods  of  re- 
currence, etc.,  nor  have  they  experienced  any  material  alteration 
by  change  of  climate." 

In  Persia  the  girls  begin  to  menstruate  at  the  age  of  9  or  10, 
and  are  often  mothers  at  11.  Mr  Burchell  says  "  the  girls  among 
the  Bushmen  are  betrothed  at  7  years  of  age,  which,  however,  im- 
plies nothing  more ; "  but,  he  adds,  "  they  are  sometimes  mothers 
at  12,  or  even  at  10  years  of  age." 

Amongst  the  Fezzaners — a  people  inhabiting  one  of  the  Eastern 
portions  of  Africa — the  females  bear  children  at  the  age  of  12  and 
13  years  ;  they  assume,  however,  at  a  very  early  age,  even  before 
they  are  20,  the  appearance  of  old  women. 

In  this  country  it  sometimes,  although,  comparatively  speaking, 
rarely  happens  that  a  woman  enjoys  marital  life  before  menstrua- 
tion has  been  evinced,  and  it  is  more  than  probable  that  this  act 
delays  its  first  occurrence.  Eecently  a  patient,  aet.  26,  came  under 
my  care  who  menstruated  for  the  first  time  at  the  age  of  23,  this 
being  two  and  a  half  years  after  marriage.  In  yet  another  case 
the  patient,  married  at  the  age  of  18,  did  not  menstruate  till  she 
was  20. 

According  to  Mr  Oldfield,  the  girls  living  in  the  hot  and  low 
country  of  the  Eboes  begin  to  menstruate  at  the  age  of  8.  In  them 
the  period  recurs  every  three  weeks,  and  lasts,  as  a  rule,  about 
three  days.  In  epileptic  patients  I  have  occasionally  noted  that 
menstruation  occurs  more  regularly  during  the  summer  than  during 
the  winter  months.  In  one  noteworthy  case  the  patient,  aged  23, 
menstruated  regularly  every  month  in  the  summer ;  the  flow,  how- 
ever, seldom  made  its  appearance  during  the  cold  months.  In  another 
patient,  suffering  from  fibroid — intramural — of  the  uterus,  it  was  re- 
marked that  the  menstrual  flow  was  always  more  abundant  and  more 
prolonged  during  the  summer  than  during  the  winter  months. 

Cold,  it  would  appear,  acts  as  a  deterrent,  serving  as  it  does  to 
delay  the  appearance  of  the  catamenial  discharge.  In  the  northern 
part  of  Germany  the  flow  seldom  appears  before  the  age  of  15,  and 
a  still  greater  delay  is  noted  in  other  colder  countries.  If,  how- 
ever, the  statement  of  Le  Bruyn  can  be  accepted,  there  is  then  at 
least  one  well-marked  exception  to  this  generalization  in  the  case 
of  the  Samoiedes,  a  tribe  inhabiting  a  part  of  Eastern  Siberia.  In 
this  country  the  climate  is  extremely  cold,  yet,  he  says,  the  females 
are  often  mothers  at  the  age  of  10  or  12  years,  and  cease  to  bear 


1889.]  FACTS   RELATIVE  TO   MENSTRUATION.  1003 

children  at  30.  In  crediting  this  publication,  it  is  well  to  re- 
member that  some  authors  have  alleged  that  these  women  never 
menstruate.  This,  Le  Bruyn  asserts,  is  wholly  untrue.  He  appears 
to  have  made  particular  inquiry  on  this  point,  and  remarks  that 
the  flow  is  very  scanty.  Another  author  has  said  that  these  women, 
when  young,  have  pendulous  breasts  and  nipples  as  black  as  coal. 
Considering  the  surroundings  of  and  harsh  treatment  to  which 
these  women  are  subjected  by  their  copartners,  it  is  astonishing 
that  the  generative  organs  display  such  a  high  degree  of  activity. 
Early  marriage  joined  to  polygamy,  together  with  the  character  of 
their  food,  may  tend  to  induce  this  anomaly.  In  the  case  of  many 
animals,  the  functional  activity  of  those  glands  which  secrete  the 
colouring  matter  of  the  hair  is  very  materially  affected  by  cold,  as 
the  hair  becomes  in  winter  perfectly  white.  This  must  in  some 
degree  be  considered  a  parallel  with  that  secretion  which  takes 
place  from  the  glands  which  stud  the  inner  lining  of  the  uterus. 

Considerable  variation,  as  regards  the  initial  establishment  and 
amount  of  the  monthly  flow,  results  not  only  from  the  influence  of 
social  life,  but  also  from  the  character  of  the  food.  Pubescence  is 
hastened  or  retarded  according  as  the  pabulum  is  more  or  less 
nutritious.  For  this  reason  girls  of  good  social  position,  and  who 
in  consequence  are  well  fed  and  partake  freely  of  the  luxuries  of 
the  table,  are  much  more  likely  to  menstruate  at  an  early  age  than 
such  as  lead  an  active  and  laborious  life,  and  who  are  at  the  same 
time  badly  nourished,  or  are,  at  least,  sustained  by  a  less  stimulat- 
ing and  less  nutritious  diet.  The  mental  state  of  the  individual 
affects  in  a  very  material  manner  the  age  at  which  the  girl  arrives 
at  puberty,  and  this  even  independently  of  her  social  position.  It  is 
quite  possible  that  the  constant  excitation  resulting  from  novel 
reading,  theatre  going,  dancing,  and  close  companionship  with  the 
opposite  sex,  may  induce  a  deterioration  of  structural  integrity  and 
functional  activity.  On  the  other  hand,  the  active  rural  life  de- 
termines a  greater  flow  of  blood  to  the  organs  of  locomotion,  and  in 
consequence  withdraws  correlatively  from  the  organs  of  generation, 
and  favours  a  more  healthy  evolution  of  the  uterine  functions.  Girls 
who  live  a  quiet  life  in  the  country  are  much  less  likely  to  suffer 
from  those  disturbances  of  a  constitutional  character,  associated 
with  the  establishment  and  each  recurrence  of  the  flow,  which  are 
so  apt  to  arise  in  young  women  exposed  to  a  life  of  excitement  in 
our  large  cities.  In  some  cases  I  have  noted  that  patients  who 
evinced  irregularity  before,  became  perfectly  regular  after  marriage, 
and  this  more  especially  after  having  given  birth  to  a  full-time 
child.  Sometimes  sexual  congress  determines  regularity.  The 
catamenial  discharge  continues,  as  a  rule,  from  three  to  six  or 
seven  days,  and  escapes  guttatim.  The  actual  amount  lost  cannot, 
however,  be  even  approximately  gauged  from  the  number  of  days 
the  flow  lasts.  It  is  alleged  that  the  excretion  varies  in  quantity 
from  8  to  12  or  even  16  ounces.     In  cold  countries  the  discharfje 


1004  DR  JAMES  OLIVER  ON  [MAY 

is  less  copious  than  in  warm.  Lapland  women  have,  as  a  rule,  a 
very  small  quantity,  whilst  the  Greenland  women  can  hardly  be 
said  to  menstruate  at  all.  In  tropical  countries,  on  the  other  hand, 
the  catamenial  discharge  is  excessive,  and  recurs  more  frequently, 
even  every  fourteen  days.  In  many  cases  the  flow,  instead  of 
being  continuously  manifested,  becomes  interrupted  ;  it  may  cease 
altogether  for  one  or  more  days,  but  reappearing,  completes  eventu- 
ally its  prescribed  cycle. 

Whether  the  menstrual  discharge  is  or  is  not  ordinary  blood  is 
still  controversial ;  that  it  contains  some  effete  material  is  surmivS- 
able,  and  this  quite  apart  from  any  admixture  with  uterine  and 
vaginal  secretion.  I  cannot  believe  it  is  the  exact  counterpart  of 
that  blood  which  flows  in  the  arteries  or  veins,  or,  as  some  authori- 
ties would  have  us  believe,  of  that  which  flows  in  the  capillaries. 
Nature  is  never  superfluous,  and  we  are  not  justified  in  surmising 
that  the  animal  economy  would,  without  some  distinct  end  in  view, 
pour  out  a  secretion  or  excretion  of  that  fluid  which  seems  to 
nourish  the  tissues  of  the  body.  It  is  more  than  probable  that  the 
catamenial  discharge  results  from  a  rapid  dissolution  of  cells.  The 
epidermal  cells,  it  would  appear,  sometimes  liquefy  in  a  similar 
manner ;  for  Mr  Bartlett,  in  his  "  Notes  on  the  Birth  of  a  Hippo- 
potamus," says, — "  The  female  hippopotamus  when  she  produced 
her  young  suffered  greatly,  and  it  was  remarked  that  the  whole 
body  was  at  the  same  time  covered  with  red-coloured  perspiration." 
Occasionally  we  see  women  who  menstruate  but  seldom,  it  may 
even  be  but  once  a  year,  whilst  others  who,  although  they  evince 
no  decided  defect  in  the  organs  of  generation,  never  menstruate  at 
all.  It  has  been  said  that  if  the  catamenia  be  irregular  in  its 
recurrences,  or  suppressed  altogether,  beauty  disappears  and  the 
health  becomes  impaired.  I  have,  however,  commonly  seen  women, 
typically  effeminate  in  every  sense  of  the  word,  with  broad  hips 
and  well-developed  breasts,  who  have  not  only  never  been  unwell, 
but  who  possess,  as  far  as  one  can  judge,  no  vestige  of  a  uterine 
system  at  all.  As  a  rule,  however,  the  discharge  recurs  about 
every  fourth  week.  It  was  at  one  time  alleged  that  the  recurrence 
had  some  direct  association  with  the  moon.  All  we  can  say  of  the 
manifestation  is  that  it  is  a  periodic  phenomenon,  and  cannot  be 
explained  any  more  than  we  can  explain  that  periodicity  which  is 
noted  regarding  many  diseases.  In  the  organic  world  periodicity 
is  manifested  in  a  variety  of  ways.  The  plant,  for  example,  has 
periodicities  which  are  determined  by  day  and  night  as  well  as  by 
seasons.  In  our  own  bodies  the  various  activities  are  subject  to 
increase  and  decrease.  The  blood  itself  is  not  propelled  continu- 
ously, but  by  impulses.  The  organism  requires  food,  and  also 
demands  repose  ;  it  cannot  eat  perpetually,  neither  must  sleep  be 
continuous,  but  interrupted  by  periods  of  activity.  It  has  been 
said,  but  with  what  truth  I  cannot  venture  any  opinion,  that  cas- 
trati  are  subject  to  periodical  haemorrhages,  which  ordinarily  pro- 


1889.]  FACTS   RELATIVE   TO   MENSTRUATION.  1005 

ceed  from  the  haemorrhoidal  vessels.  With  the  approach  and 
appearance  of  the  monthly  flow,  the  whole  frame,  as  one  would 
naturally  expect  from  what  has  already  been  stated,  participates 
more  or  less  markedly  in  the  change,  and  the  amount  of  disturb- 
ance experienced  as  well  as  manifested  is  commensurate  with  the 
power  the  organism  possesses  of  adaptation,  and  hence  of  equilibra- 
tion. Simple  determination  of  blood,  because  of  increased  func- 
tional activity,  to  the  other  pelvic  organs,  of  itself  produces  a 
definite  alteration  in  the  waves  of  molecular  motion  proceeding 
therefrom,  and  these,  radiated  in  all  directions,  affect  the  vascular 
state  of  otlier  very  important  structures,  remote  though  they  be 
from  the  initial  disturbing  centre. 

In  many  chronic  disorders,  of  whatever  system,  affecting  the 
female,  every  observer  must  have  remarked  that,  according  to  the 
menstrual  type  of  the  individual,  there  is  often,  either  in  anticipa- 
tion or  with  the  appearance  of  the  flow,  a  proneness  to  aggravation, 
or  in  some  very  exceptional  cases  to  alleviation  of  symptoms ;  and 
with  the  cessation  or  disappearance  a  corresponding  gradual  rever- 
sion to  the  originally  stationary  or  slowly  progressive  state.  In 
some  few  cases  the  loss  of  blood  may  possibly  account  for  much  of 
the  disturbance  manifested,  yet  it  cannot  be  the  sole  factor.  In 
many  women,  where,  from  some  inexplicable  cause,  there  is  for  a 
more  or  less  indefinite  period  a  total  suppression  of  the  character- 
istic discharge,  I  have  frequently  detected  such  a  regularly  recurring 
alteration  in  the  symptoms  or  manner  of  the  patient  as  to  place 
beyond  denial  the  direct  relationship  of  the  disturbance  to  the 
catamenial  cycle. 

In  no  class  of  disorder  do  we  find  so  regularly  and  markedly  an 
interference  with  the  outward  manifestation  of  uterine  activity  as 
in  epilepsy,  a  disease  the  pathology  of  which  is  still  undetermined. 
It  is  more  than  probable,  however,  that  as  we  may  consider  the 
epileptic  female  as  epileptic  throughout,  even  to  the  finger  tips, 
the  interruption  of  the  periodically  recurring  functional  disturb- 
ance in  the  uterus  is  the  result  of  some  occult  condition  of  the 
corpuscular  elements  governing  the  activity  of  this  organ,  and 
therefore  wholly  independent  of  any  defective  structural  state  of 
the  viscus  itself.  Under  such  circumstances,  however,  the 
structural  integrity  of  the  uterus  may  eventually  suffer,  for 
inaction  and  over-action  alike  tend  to  exert  a  prejudicial 
influence. 

Gestation  as  a  rule,  although  not  invariably,  determines  for  a 
period  of  nine  months  a  cessation  of  the  catamenial  discharge. 
Not  unfrequently,  however,  we  see  women  who  throughout  one  or 
more  pregnancies  continue  perfectly  regular,  the  amount  even  and 
character  of  the  flow  being  unaltered  by  the  physiological  process 
going  on  in  the  uterus ;  and  this  habit,  once  firmly  established,  is 
likely  to  be  perpetuated,  and  consequently  inherited.  In  the  fol- 
lowing  case    menstruation  was   manifested   continuously  during 


1006  DK  JAMES   OLIVER   ON  [MAY 

gestation  as  well  as  lactation : — Henrietta  B.,  aged  29,  began  to 
menstruate  at  the  age  of  11,  the  flow  lasting  as  a  rule  three 
days.  Married  at  the  age  of  15,  she  had  given  birth  to  seven 
full-time  children,  and  one  at  the  seventh  month.  The  child 
prematurely  born  died  soon  after  birth  ;  all  the  others  were 
suckled  for  two  or  three  months,  as  the  patient  invariably 
became  pregnant  whilst  suckling.  During  each  pregnancy, 
from  first  to  last,  the  menstrual  discharge  recurred  regularly  every 
month,  the  amount  lost  varying  but  little,  and  the  flow  continuing 
for  the  usual  number  of  days  (three).  During  lactation  the  same 
cycle  was  maintained.  This  woman,  although  she  invariably  experi- 
enced morning  sickness  soon  after  conceiving,  was  still  unable  to 
suspect  with  certainty  the  existence  of  pregnancy  until  the  fourth 
month,  at  which  time  the  movements  of  the  child  in  utero  were 
usually  appreciated.  In  such  cases  the  catamenial  discharge  is 
secreted  by  one  cavity  of  a  bipartite  uterus,  or  from  that  part  of 
the  uterus  which  is  free  from  placental  involvement.  Usually  the 
fertilized  ovum  affects  in  some  inexplicable  manner  the  uterine 
organ,  which  is  destined  for  a  time  to  be  its  only  source  of  nutri- 
tion ;  and  the  gradual  molecular  changes  so  produced  and  radiated 
to  the  higher  uterine  centre  alter  here  the  corpuscular  state,  and 
determine  the  sequence  of  events.  Disturbance  of  the  pneumo- 
gastric  centre,  because  of  its  surmised  proximity  to  the  uterine 
centre,  commonly  follows  impregnation ;  hence  the  reason  that 
sickness  is  an  almost  invariable  association  of  pregnancy. 

During  the  period  of  lactation  and  consequent  activity  of  the 
mammary  glands,  we  find  not  only  the  external  manifestation  of 
the  recurring  functional  change  of  the  uterus  held  in  abeyance ; 
but  also  the  activity  of  the  generative  glands,  as  impregnation 
rarely  occurs  whilst  the  mother  continues  to  suckle  the  offspring. 
Amongst  women  of  the  lower  classes  the  opinion  prevails,  that  so 
long  as  they  continue  to  suckle  it  is  impossible  that  they  can 
become  pregnant.  In  the  main  this  is  true,  yet  it  is  well  to 
remember  that  if  lactation  be  too  long  continued  the  mammaiy 
glands  in  the  human  female  will,  as  in  the  case  of  the  milk  cow, 
become  gradually  habituated  to  the  change,  and  remain  active, 
whilst  the  organs  of  generation  regain  their  full  functional  activity. 
The  life  of  every  organism  is  twofold — first  the  maintenance  of 
the  individual,  and  then  the  perpetuation  of  the  species.  The 
latter  is  generally  subservient  to  the  former.  It  sometimes 
happens,  and  the  tendency  appears  in  many  cases  to  be  inherited, 
that  whilst  the  child  is  being  suckled  by  the  mother,  the  organs  of 
generation  continue  active,  and  the  catamenial  discharge  recurs 
with  its  wonted  regularity  and  without  any  variation  as  to  amount. 
When  this  train  of  events  occurs  too  early,  and  impregnation 
results  too  frequently,  the  physical  state  of  the  woman  is  apt  to 
suffer  in  a  very  marked  degree. 

In  women  who  have  borne  one  or  more  children,  the  mammary 


1889.]  FACTS   RELATIVE  TO   MENSTRUATION.  1007 

glands  may  continue  to  secrete  actively  for  some  time  after  wean- 
ing the  last  child,  and  this  independently  of  the  existence  of  that 
uterine  excitation  consequent  upon  impregnation.  In  such  cases 
the  secretion  is  sometimes  held  in  abeyance  during  menstruation. 
C.  S.,  aet.  28,  and  married  four  years,  had  given  birth  to  a  full-time 
child  twelve  months  after  marriage,  and  eighteen  months  sub- 
sequently she  was  the  subject  of  a  miscarriage,  being  then  three 
months  pregnant.  Ever  since  the  birth  of  the  child,  three  years 
ago,  the  activity  of  the  mammary  glands  has  continued.  During 
menstruation  the  mammary  turgescence  subsides,  and  no  milk  is 
at  this  time  obtainable  from  either  breast.  The  secretion  appears 
again  immediately  on  the  cessation  of  the  monthly  flow. 

Menorrhagia,  as  I  have  already  remarked,  is  a  symptom  fre- 
quently associated  with  pyonephrosis  in  the  early  days  of  the  dis- 
ease, and  more  especially  when  the  change  exists  in  the  left  kidney. 
This  appears  to  me  to  result  from  some  reflex  nerve  influence, 
and  is  capable  of  being  explained  very  much  in  the  same  way  as 
the  passage  of  a  slightly  alkaline  fluid  into  the  duodenum  deter- 
mines forthwith  a  copious  secretion  of  bile.  The  liver,  it  is  to  be 
remembered,  is  in  direct  communication  with  the  duodenal  part  of 
the  intestine ;  and  considering  that  the  renal  and  uterine  organs  are 
developed  from  the  same  primordial  structure,  it  is  not  irrational 
to  surmise  the  existence  in  the  adult  state  of  a  direct  nerve  com- 
munication. In  inflammation  of  the  mucous  lining  of  the  Fallopian 
tube,  with  puro-fibrinous  exudation  and  accumulation,  menorrhagia 
is  frequently  an  associated  symptom,  and  apparently  results  from 
some  interference  with  the  nerve  supply  to  the  uterus.  It  is  more 
than  likely  that  the  nerves  governing  the  functions  of  the  uterus 
are  transmitted  along  the  Fallopian  tubes,  and  although  menstrual 
disorders  may  frequently  result  with  distinct  pathological  changes 
existing  in  such,  we  must  not  too  hastily  conclude  that  these 
structures  per  se  govern  the  uterine  changes.  In  the  science  of 
Medicine  there  is  no  question  more  difi&cult  than  that  of  deter- 
mining cause  and  effect. 

In  cases  of  ansemia  we  often  witness  either  diminution  or  total 
suppression  of  the  menses,  rarely  menorrhagia.  As  we  regain  the 
healthy  state,  the  function  becomes  re-established  and  maintained 
as  it  was  wont.  In  such  cases  the  functional  activity  of  the  uterus 
may  cease  or  be  lessened,  not  only  because  the  nutrition  of  the 
nerve  centre  is  defective,  but  also  because  the  organ  itself  is  badly 
nourished.  Functional  activity  is  associated  with  waste  in  every 
animal  structure,  and  the  structural  integrity  is  maintained  by  the 
tissue  appropriating  from  the  blood  circulating  in  it  the  ingredients 
necessary  for  its  well-being.  The  blood  of  an  anaemic  patient  is 
wholly  unfit  for  nourishing  nerve  tissue,  the  functional  activity  of 
which  becomes  in  such  cases  consequently  enfeebled  and  wholly 
incapable  of  evoking  spontaneously  the  train  of  events  associated 
with  menstruation.     In  order  that  the  functional  activity  of  any 


1008  DR  JAMES   OLIVER   ON  [.MAY 

organ  shall  continue  unimpaired,  the  nutrition  must  be  main- 
tained. 

The  true  nature  of  the  catarnenial  discharge  is  still  conjectural, 
yet  its  elimination  from  the  body  renders  it  highly  probable  that 
having  already  served  some  special  end,  its  detention  in  the  blood 
may  exert  some  deleterious  influence  on  the  animal  economy.  It 
is  generally  admitted  that  ovulation  and  menstruation  are  co- 
incident ;  that  they  may,  or  may  not  be,  I  am  not  prepared  to 
dispute ;  that,  however,  they  are  invariably  associated  there  seems 
to  me  much  reason  for  doubt.  That  the  discharge  of  an  ovum 
may,  and  frequently  does,  occur  quite  independently  of  menstrua- 
tion, I  have  no  misgivings.  No  one  would  entertain  the  idea  of 
gauging  the  reproductive  power  of  a  female  either  from  the  regu- 
larity or  amount  of  the  catamenial  discharge.  I  have  occasionally 
noted  that  women  who  menstruated  with  marked  irregularity  are 
prolific. 

It  is  alleged,  as  an  established  theorem,  that  from  the  period  of 
puberty  to  the  climacteric  age,  there  is,  besides  a  gradual  death  of 
the  mucous  membrane  lining  the  whole  uterine  cavity — which 
must  ever  occur  to  be  compatible  with  life — a  more  or  less  regu- 
larly recurring  and  complete  death  of  this  coat.  In  the  whole 
animal  kingdom  we  search  in  vain  for  a  physiological  change  truly 
analogous  with  this.  The  serpent,  it  is  true,  may  shed  its  skin 
more  or  less  intact ;  but  ere  it  casts  off  the  old  coat  a  new  one  is 
already  regenerated  to  protect  its  body  from  all  extraneous  in- 
jurious influences.  In  vital  structures  change  is  wont  to  be 
gradual ;  creation  and  destruction  proceed  together.  There  is 
apparently  no  departure  from  this  inexorable  law.  Death  of 
the  mucous  lining  of  the  uterus  takes  place  imperceptibly ; 
and  the  change,  as  in  all  organs  of  the  body,  is  one  ever 
going  on. 

In  several  cases  I  have  examined  uteri  removed  from  women 
who  have  died,  not  only  during  menstruation,  but  just  before  an 
expected  period.  In  two  cases  the  death  was  sudden,  the  patient 
at  the  time  being  in  apparent  good  health.  In  three  cases  the 
uterine  organ  was  invaded  by  growths  of  a  fibroid  character,  which 
were  chiefly  submucoid.  To  the  naked  eye  the  mucous  lining 
appeared  in  all,  in  every  respect,  like  that  of  a  normal  uterus 
examined  at  any  time  indiscriminately.  In  no  case  did  I  detect 
any  breach  in  the  continuity  of  the  lining  membrane  of  the  uterus, 
except  in  those  in  which  this  organ  had  become  the  seat  of  fibroid 
growths.  In  such  the  mucous  lining  had  in  places  become  markedly 
attenuated  or  vanished  altogether,  but  this  merely  because  of  a 
vital  pressure  exerted  constantly  on  this  coat  by  the  underlying 
new  growth.  Here  gradual  absorption  had  resulted  very  much  in 
the  same  manner  as  bone,  and  soft  tissues  disappear  before  the 
constant  pressure  of  an  increasing  aneurism.  I  have  never  at  any 
time  detected  any  evidence  of  structural  change  microscopically  in 


1889.]  FACTS   RELATIVE  TO   MENSTRUATION.  1009 

the  inner  lining  of  the  uterus  in  cases  in  which  this  organ  has  been 
removed  from  the  bodies  of  females  who  have  died  either  during 
or  just  before  an  expected  menstruation.  The  glands  which  stud 
the  inner  coat  of  the  uterus  in  its  entirety,  consisting  of  columnar 
cells  lined  by  a  basement  as  well  as  a  limiting  membrane,  have,  how- 
ever, shown  marked  enlargement,  in  many  cases  so  pronounced,  that 
the  outline  not  only  of  each  individual  cell,  but  of  the  gland  itself, 
has  been  lost.  The  columnar  cells  appear  swollen,  and  contain 
frequently  large  corpuscular-looking  bodies,  which,  I  believe,  are  a 
simple  manifestation  of  increased  functional  activity.  Prior  to 
cutting  the  sections  by  freezing  in  gum,  the  tissues  had  been 
hardened  for  two  days  in  spirit,  and  finally  placed  in  a  weak 
solution  of  chromic  acid.  The  specimens  examined  were  stained 
in  a  variety  of  ways.  The  best,  however,  and  that  affording  the 
clearest  definition,  was  iron  and  pyrogallic  acid. 

Those  who  support  the  denudation  theory  assert  that  each 
recurring  monthly  flow  is  anticipated  by  a  fatty  degeneration  of 
the  mucous  lining  of  the  uterus,  blood  is  thereafter  extravasated 
into  its  substance,  and  eventually  the  whole  becoming  disintegrated 
is  washed  away  imperceptibly  with  the  escaped  blood.  A  new 
mucous  membrane  is  thereafter  by  degrees  regenerated  from  the 
inner  layer  of  the  muscular  coat,  which  in  its  turn,  too,  like  its 
predecessor,  must  undergo  a  similar  degenerative  change,  and  be 
ultimately  removed  from  the  body. 

Some  of  the  lower  animals,  it  is  true,  retain  the  power  of  repro- 
ducing limbs,  and  possibly  other  parts  of  the  body,  when  such 
are  removed  by  accident.  If  the  separation  of  a  part  be  too 
frequently  practised,  we  eventually  exhaust  the  power,  the  struc- 
tural integrity  of  the  regenerated  limb  or  tissue  becoming  less  and 
less  marked  with  each  removal. 

Clinically,  if  the  mucous  membrane  of  the  uterus  were  shed 
with  each  catamenial  flow,  it  must  be  capable  of  completing  its 
cycle  of  degeneration,  shedding,  and  regeneration  in  an  incredibly 
small  number  of  days.  The  menstrual  anomalies  which  preclude  the 
acceptance  of  such  a  dogma  are  many.  Taking  all  the  facts  into 
consideration,  it  is  more  than  probable,  therefore,  that  the  recurring 
monthly  discharge  of  the  human  female  is  a  secretion,  or  rather 
an  excretion  from  the  glands  which  stud  the  lining  of  the  uterus 
and  Fallopian  tubes,  without  degenerative  change  other  than  that 
commonly  associated  with  augmented  functional  activity,  and 
comparable  with  that  occurring  in  any  other  organ  of  the  body 
under  similar  circumstances. 


EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.   XI.  6  M 


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1014  DR  J.   H.  groom's   cases   OF  ABDOMINAL   SECTION.  [MAY 


1889.]         DR  J.   H.   CUOOM's   CASES   OF   ABDOMINAL   SECTION.  I015 

The  present  table  represents  my  abdominal  work  up  till  the 
present  time,  130  cases. 

The  first  group  of  108  completed  ovariotomies  and  removal  of 
uterine  appendages  and  tumours  of  various  kinds  does  not  require 
any  special  comment.  Of  this  group  there  were  56  completed 
ovariotomies,  and  52  cases  of  removal  of  the  uterine  appendages  for 
various  conditions.  The  deaths,  of  which  there  were  four,  all 
occurred  in  the  ovariotomies  proper.  Two  were  due  to  fatty  heart, 
and  each  occurred  unexpectedly  and  suddenly ;  one  was  due  to  per- 
foration of  a  gastric  ulcer,  and  one  to  shock.  They  were,  there- 
fore, all  unforeseen,  and,  so  far  as  I  know,  unavoidable.  In  the  cases 
of  removal  of  the  uterine  appendages  there  were  no  deaths  whatever. 

With  regard  to  the  appendage  work,  I  feel  on  looking  over  the 
recent  as  well  as  the  remote  results,  that  these  operations  are  in  the 
main  entirely  satisfactory.  I  have  performed  the  operation  for 
varying  conditions,  52  times  without  a  death.  Of  course  this  is 
but  one  part  of  the  result.  The  larger  question  involved  in  the  in- 
quiry is,  whether  the  permanent  result  is  satisfactory.  I  need  not 
refer  again  to  the  subject  in  detail,  as  I  have  already  published 
the  remote  results,  so  far  as  my  cases  are  concerned,  in  the  Inter- 
national Journal  of  Medical  Sciences.  Briefly  the  results  in  34  cases 
after  the  lapse  of  not  less  than  a  year  were : — 

For  bleeding  fibroid,  6  cases. — Four  complete  cures  both  of  pain 
and  haemorrhage.  One,  no  benefit  at  last  report.  One  had  not  com- 
pleted the  year,  so  far  is  improving. 

For  bleeding  uterus,  where  no  fibroid  could  be  detected,  2  cases. 
— Both  complete  cures. 

For  dysmenorrhosa,  3  cases.  —  Cures  complete.  Two  have 
entirely  ceased  to  menstruate ;  one  menstruates  irregularly,  but 
without  pain. 

For  hcematosalpinx,  4  cases. — All  cured. 

For  double  hydrosalpinx,  1  case. — Cured. 

For  simple  or  gonorrhoeal  salpingo-oophoritis  18  cases. — In  4  no 
record ;  2,  ventral  hernia,  but  no  pain ;  5,  cure  complete ; 
1  up  to  present  a  failure ;  5  doubtful  as  yet ;  1  dyspareunia  con- 
tinues, but  pelvic  pain  is  gone. 

Of  the  5  doubtful  cases, one  was  a  hysterical  woman  whom  I  would 
not  now  touch.  Another  was  an  incomplete  operation,  one  ovary 
being  left.  This  case  ought  really  not  to  be  included.  In  the 
others  the  cure  is  retarded  by  some  subsequent  parametric  inflam- 
mation. 

Such  is  the  state  of  the  facts  after  not  less  than  a  year  in  32 
cases,  and  I  think  the  results  justify  the  operations. 

I  believe  that  report  erred  in  allowing  too  short  a  time  to  elapse 
between  the  report  and  the  operation ;  for  example,  2  cases  of 
haematosalpinx,  which  in  the  International  Journal  I  stated  were 
failures,  have  turned  out  entirely  successful.  There  will  always  be 
diSiculty  in  arriving  at  the  truth  about  Hospital  cases.     It  is  cer- 


1016         DR  J.   H.   groom's   cases   OF  ABDOMINAL   SECTION.         [MAY 

tainly  a  difficulty  which  I  have  experienced  in  giving  accurate  re- 
ports about  patients  at  long  intervals  after  they  have  left  Hospital. 

In  bleeding  fibroids,  always  provided  they  are  not  larger  than  a 
four  months'  pregnancy,  I  have  had  much  satisfaction.  I  am  well 
aware  that  there  is  a  variety  of  soft  myoma  which  is  not  influenced 
by  removal  of  the  ovaries,  except  rather  to  be  stimulated  to  fresh 
growth ;  but  so  far  as  my  knowledge  goes,  I  have  not  met  with 
any  such  as  yet  in  my  own  practice,  though  I  have  seen  a  case 
in  which  the  ovaries  were  removed,  where  the  tumour  increased 
in  size,  and  in  which  the  patient  died  directly  from  uterine  hsemor- 
rhage  two  years  after. 

I  feel  disposed  to  think  that  in  removal  of  the  uterine  append- 
age, the  cases  where  failure  is  met  with  are  in  hysterical  women, 
and  in  them,  so  far  as  my  experience  goes,  no  matter  what  their 
alleged  pain  may  be,  removal  of  the  appendages  in  no  way  benefits 
them,  but  only  brings  discredit  on  the  operation.  This  is  one  of 
the  many  reasons  which  oblige  me  to  say  that  the  removal  of  the 
ovaries  for  simple  dysmenorrhoea  is  an  operation  to  be  as  a  rule 
avoided.  Certainly  it  is  not  one  to  be  lightly  undertaken.  I  refer, 
of  course,  to  the  removal  of  the  healthy  ovaries.  Uncompli- 
cated dysmenorrhoea  can,  as  a  rule,  be  cured  or  relieved  by  other 
means,  but  in  women  over  thirty  years  of  age,  with  long-standing 
dysmenorrhoea,  and  where  menstruation  exhausts  and  prostrates 
them,  and  makes  their  lives  miserable,  the  ovaries  are  then  gener- 
ally cystic,  and  scarcely  come  under  the  category  of  normal  organs. 
Then  after  other  means  have  failed,  removal  can  do  no  harm,  and 
generally  gives  the  desired  relief. 

It  is  a  curious  fact  that  I  have  only  met  with  one  case  of  pyo- 
salpinx,  though  that  condition  is  described  as  so  constantly 
occurring  in  the  practice  of  other  men.  I  have  met  many  cases  of 
salpingitis,  both  simple  and  specific,  where,  on  microscopic  ex- 
amination, pus  corpuscles  could  be  found  more  or  less  numerous. 
By  pyosalpinx  I  mean  a  swollen,  dilated,  sacciform  tube  contain- 
ing pus.  The  sketch  (Plate  I.)  is  a  fair  reproduction  of  this  case. 
My  reading  and  personal  information  leads  me  to  the  conclusion 
that  such  tumours  in  other  places  are  exceedingly  common.  In 
Birmingham,  London,  America,  there  seems  a  very  large  propor- 
tion of  this  class  of  cases.  I  mention  this  fact  now  to  ascertain 
whether  it  is  merely  an  accident  in  my  case,  or  whether  my 
experience  coincides  with  that  of  the  other  members  of  this 
Society.  If  the  latter  should  turn  out  to  be  the  case,  the  infer- 
ence to  be  arrived  at  is  clearly  that  that  specific  disease  is  less 
prevalent  here  than  elsewhere. 

I  should  like  to  draw  attention  briefly  to  Case  58.  She  was 
a  woman  of  somewhat  weak  intellect,  suffering  from  a  large 
polycystic  ovarian  tumour.  It  was  everywhere  adherent,  and 
occupied  me  longer  than  I  have  ever  been  over  any  other  case. 
It  was  impossible  to  separate  it  from  the  enlarged  uterus,  and, 


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1889.]         DR  J.   H.   groom's   CASES   OF  ABDOMINAL   SECTION.  1017 

therefore,  I  was  obliged  to  remove  the  uterus  entirely  with  the 
tumour,  and  of  course  leave  an  extra-peritoneal  stump  with  the 
ordinary  Koeberle  clamp.  Three  days  after  the  operation  the 
patient  tore  off  the  bandage  and  sat  over  the  edge  of  the  bed,  and 
it  was  only  with  difficulty  she  was  prevented  dragging  off  the 
clamp.  She  became  violent,  and  had  to  be  sent  to  the  delirium 
tremens  ward,  and  afterwards  to  an  asylum.  The  point  of  interest, 
however,  is  that  in  the  stump  had  been  included  the  left  ureter, 
and  there  is  a  leakage  of  urine  per  abdomen.  How  this  is  to  be 
cured  except  by  the  removal  of  the  corresponding  kidney  I  do  not 
know.  In  the  meantime  it  affords  a  field  for  some  physiological 
experiments. 

No.  48  is  a  remarkable  case,  probably  unique.  The  patient 
was  sent  to  me  with  constant  pelvic  pain.  I  found  a  tumour  per 
vaginam  as  large  as  a  big  orange,  which  I  took  to  be  a  dilated 
tube.  On  opening  the  abdomen  and  introducing  my  hand  into 
the  pelvis,  I  found  a  round  tumour  lying  on  the  posterior  wall  of 
the  broad  ligament.  This  came  away  in  my  hand  without  any 
trace  of  bleeding  whatever,  having  seemingly  scarcely  any  attach- 
ment at  all.  The  ovaries  were  healthy  on  both  sides,  and 
therefore  were  not  interfered  with.  This  curious  tumour  on 
section  turned  out  to  be  organized  blood-clot,  contained  in 
muscular  walls,  and  seems  to  me  to  have  been  a  portion  of  the 
Fallopian  tube  which  had  been  distended,  and  at  the  point  of 
stricture  had  become  greatly  thinned,  and  had  thus  easily  come 
off  on  the  least  manipulation.  The  accompanying  sketch  (Plate 
II.)  gives  an  excellent  representation  of  this  curious  tumour. 

The  group  which  seems  to  me  to  present,  from  a  clinical  point 
of  view,  features  of  most  interest,  is  that  of  the  cases  of  tubercular 
^peritonitis  with  encysted  fluid. 

In  this  group  there  are  three  cases.  I  wish  first  to  direct  atten- 
tion to  those  numbered  121  and  123.  They  were  women  both  in  the 
prime  of  life,  and  both  enjoying,  except  for  the  abdominal  swell- 
ing, perfectly  good  health.  They  were  sent  to  the  ward  as  cases 
of  ovarian  tumour,  and  such,  after  careful  examination,  I  took 
them  to  be.     This  very  point  of  diagnosis  was  most  important. 

In  each  case,  for  they  were  practically  parallel,  there  was  an 
abdominal  swelling  reaching  to  the  umbilicus,  regular,  even,  fluc- 
tuating. There  was  dulness  on  percussion  all  over,  and  resonance 
in  the  flanks.  There  was  no  history  of  any  concurrent  disease 
whatever.  The  temperature  was  normal,  and  the  patients  com- 
plained of  no  discomfort  or  suffering  except  the  swelling. 

When  the  patients  presented  themselves  at  the  Hospital,  the 
tumours  had  been  in  course  of  development  from  four  to  eight 
months  respectively ;  and,  so  far  as  I  am  aware,  were  quite  undis- 
tinguishable  from  ordinary  parovarian  tumours.  Were  such  cases 
to  present  themselves  to  me  again,  I  know  of  no  way  of  preventing 
a  similar  error  in  diagnosis.     Immediately  the  peritoneum  was 

EDINBURGH  MED.   JOURN.,   VOL.   XXXIV. — NO.   XI.  6  N 


1018      DR  J.  II.  groom's  cases  of  abdominal  section.       [may 

reached  the  mistake  was  plain  and  the  treatment  obvious — empty 
the  abdomen  of  the  straw-coloured  fluid,  wash  out  with  an  anti- 
septic, and  drain.  I  did  not,  in  the  first  instance,  drain  in  either 
of  these.  In  the  first  case,  after  thoroughly  removing  all  the 
peritoneal  fluid  and  careful  irrigation,  there  was  no  reaccumulation 
when  the  patient  left  the  ward  in  six  weeks.  The  second  case  was 
treated  in  a  similar  manner ;  in  her  case  after  her  return  home  the 
fluid  collected,  and  she  had  to  be  drained.  That  these  were  genuine 
cases  of  tubercular  hydroperitoncum,  the  examination  of  the  peri- 
toneum as  well  as  their  after  clinical  history  made  certain.  The 
peritoneum  on  being  everted  was  thickly  studded  over  with  miliary 
sago-grain  deposits.  It  is  a  striking  fact  that  such  advanced  tuber- 
cular disease  should  have  been  found  without  at  any  time  giving 
rise  to  any  general  symptoms  or  any  rise  of  the  temperature. 
Professor  Gairdner  of  Glasgow  in  a  recent  lecture  drew  attention 
to  cases  of  a  somewhat  similar  nature  occurring  in  children. 
The  opening  of  the  abdomen  and  evacuation  of  the  fluid  ex- 
plained the  anomalous  physical  signs.  The  want  of  clear 
percussion  on  the  surface,  so  usual  in  peritoneal  dropsy,  and 
its  presence  in  both  flanks,  was  accounted  for  by  the  fact  that 
in  an  early  stage  of  the  disease  the  intestines  had  been  bound 
down  posteriorly  and  to  the  sides  by  plastic  inflammation ;  the 
fluid  developing  afterwards  became  encysted  anteriorly.  The 
after  history  of  these  cases  is  interesting.  In  both,  a  week  after,  the 
temperature  began  to  show  evening  rises  and  morning  falls  with 
night  sweats.  In  neither  could  any  physical  signs  of  tubercular 
disease  be  detected  before  leaving  Hospital.  Both  patients  are 
still,  so  far  as  I  know,  living,  but  one  has  developed  tubercular 
disease  in  the  lungs,  and  the  other  abdominal  phthisis.. 

The  third  case  in  this  group  is  one  of  encysted  2^critonitis,  dis- 
covered only  after  the  abdomen  was  opened.  Mrs  L.,  ten  years 
married  and  sterile,  had  suffered  all  her  married  life  constant  pelvic 
pain,  with  occasional  inflammatory  attacks  in  the  pelvis.  She  had 
the  appearance  of  a  woman  who  had  gone  through  long  suffering. 

On  examining  per  vaginam  the  uterus  was  fixed,  and  there  was 
on  the  left  side  a  tumour  the  size  of  an  orange.  This  was  diagnosed 
as  a  distended  tube.  On  opening  the  abdomen  there  was  well- 
marked  indication  of  chronic  tubercular  peritonitis,  and  the  swell- 
ing on  the  left  side  turned  out  to  be  an  accumulation  of  encysted 
peritoneal  fluid.  The  ovaries  and  tubes  had  no  relation  to  it.  The 
cyst  was  ruptured  and  washed  out.  In  this  case  there  has  been 
no  recurrence,  but  a  distinct  relief  to  the  symptoms,  and  up  to  the 
present  a  marked  improvement  in  health. 

These  cases  illustrate  a  form  of  tumour  which  does  present  itself 
from  time  to  time.  I  have  searched  and  found  a  considerable 
number  recorded  in  various  journals,  where  a  similar  mistake  was 
made.  Others  have  recorded  better  results  than  mine,  I  mean  that 
after  evacuation  the  patient  was  entirely  restored  to  health,  no 


1889.]         DR  J.   H.    groom's  CASES  OF  ABDOMINAL  SECTION.         1019 

recurrence  taking  place  of  the  tubercular  disease  anywhere  else. 
Taking  an  average,  it  would  seem  that  about  a  fourth  make  entire 
recoveries  and  the  remainder  pursue  similar  courses  to  mine. 

The  last  group  is  certainly  entirely  satisfactory,  I  mean  the 
cases  of  suppurating  peritonitis,  when  the  abdomen  and  pelvis  were 
filled  with  fcetid  stinking  pus.  Washing  and  draining  effected  a 
complete  cure  in  each  case.  Both  my  hysterectomies  died.  I  gave 
details  of  both  these  cases  in  a  former  report. 

With  regard  to  Group  II.,  it  is  as  well  to  be  clear  as  to  what  is 
meant  by  an  exploratory  incision.  I  mean  one  of  two  things : — 
Either  that  I  opened  the  abdomen  and  found  my  diagnosis  wrong 
— as,  for  example,  in  the  fihro-cellular  tumour  of  omentum,  the 
case  of  encysted  hcematocele,  or  the  sarcoma  involving  the  liver — 
which  latter,  I  am  bound  to  say,  I  mistook  for  an  ordinary  ovarian 
tumour,  and,  of  course,  closed  the  abdomen  at  once;  or  that  I 
opened  the  abdomen  and  found  my  diagnosis  right,  but  the  tumour 
one  which  did  not  admit  of  further  surgical  interference,  mostly 
malignant.  Of  eleven  such  cases  seven  died,  directly  and  definitely, 
of  the  disease,  without  any  reference  to  the  section. 

Such  cases  are  not  usually  placed  on  record  in  statistics,  but  I 
think  it  right  in  making  a  report  to  state  every  case,  without 
making  any  exceptions.  These  cases  add  nothing  whatever  to  our 
information  as  to  the  average  mortality  of  any  operation.  I  am 
therefore  justified  in  excluding  these  cases  in  estimating  the  mor- 
tality all  over  my  abdominal  work,  which  would  thus  amount  to 
six  per  cent. 

In  the  management  of  abdominal  section  I  consider  the  points 
essential : — First,  Careful  management  of  the  patient  beforehand, 
especially  in  the  direction  of  baths  and  free  purgation,  as  well  as 
rest  in  bed  for  a  week  before ;  second,  careful  attention  to  details 
during  the  operation ;  thii^d,  free  irrigation  after  every  operation 
where  there  has  been  the  least  unusual  manipulation  or  haemor- 
rhage ;  and  fourth,  the  use  of  the  drainage-tube. 

All  my  operations  have  been  performed  with  careful  antiseptic 
precautions,  and  I  have  never  seen  any  bad  effect  from  the  use  of 
antiseptics,  except  in  one  case  where  there  was  very  considerable 
haemorrhage  from  the  bowels,  which  I  could  account  for  in  no 
other  way  than  as  a  result  of  the  perchloride  of  mercury.  I  have 
never,  so  far  as  I  know,  had  any  death  attributable  directly  to 
sepsis  or  peritonitis.  One  of  the  most  annoying  minor  troubles 
after  the  operation  has  been  suppurating  stitch-holes.  I  neither 
know  why  this  occurs,  nor,  of  course,  how  to  prevent  it. 


1020  DR  G.   A.   GIBSON   ON  THE  [MAY 

IV.— AN  EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 
STOKES  RESPIRATION. 

By  G.  A.  Gibson,  M.D. 

(  Continued  from  page  900.) 

Saloz^  devotes  his  inaugural  dissertation  to  the  subject  of 
Cheyne-Stokes  respiration,  and  embodies  in  its  pages  a  large 
number  of  interesting  facts,  clinical  and  experimental.  After 
defining  this  type  of  respiratory  rhythm,  and  distinguishing  it 
from  such  respiratory  phenomena  as  are  common  in  meningitis, 
he  proceeds  to  analyze  its  symptoms,  taking  up,  in  the  first  place, 
the  phenomena  shown  by  the  respiration,  and,  in  the  next  place, 
those  connected  with  the  circulatory,  psychical,  visual,  and  motor 
apparatus.  He  lays  stress  on  the  variability  of  the  circulatory 
phenomena ;  on  the  necessity  that  any  theory  explaining  the  origin 
of  Cheyne-Stokes  respiration  must  give  a  reason  for  the  changes 
in  the  mental  state  frequently  accompanying  it ;  on  the  support 
which  the  oculo-pupillary  symptoms  give  to  Ptosenbach's  theory ; 
and  on  the  inconstancy  of  the  muscular  phenomena. 

He  states  that  the  appearance  of  Cheyne-Stokes  breathing  is 
frequently  preceded,  and  its  disappearance  followed,  by  a  form  of 
respiratory  rhythm  which  may  be  termed  "intermediate,"  as  it 
forms  a  transition  from  the  normal  rhythm  to  that  of  Cheyne- 
Stokes  breathing,  and  calls  attention  to  the  fact  that  sleep  is  very 
favourable  to  the  development  of  the  symptom.  Casting  a  glance 
at  the  views  of  Cuffer  and  his  division  of  the  type  into  two  classes, 
he  proceeds  to  review  several  of  the  theories  advanced  to  account 
for  it,  particularly  those  of  Traube,  Filehne,  Luchsinger  and  Solo- 
kow,  and  Cuffer.  In  the  course  of  this  criticism  he  enunciates  the 
following  proposition: — That  the  pathological  physiology  of  Cheyne- 
Stokes  respiration  must  be  based  on  the  three  conditions, — (1), 
Diminution  of  the  excitability  of  the  respiratory  centre ;  (2),  Rapid 
exhaustion  of  this  excitability  by  excessive  action;  and,  (3), 
Gradually  increasing  recovery  of  this  excitability,  even  amounting 
to  transitory  exaggeration.  In  reviewing  Cuffer's  work  he  observes 
that  in  the  renal  cases  which  he  has  seen  presenting  this  symptom 
there  have  been, — (1),  Alterations  of  the  arterial  system,  embracing 
the  vessels  at  the  base  of  the  brain,  leading  to  defective  irrigation 
of  the  medulla ;  (2),  Consecutive  cardiac  lesions  augmenting  the 
circulatory  troubles  ;  and,  (3),  An  abnormal  state  of  the  blood, 
which  presented  a  great  tendency  to  coagulate  and  cause  throm- 
bosis. 

After  some  brief  remarks  on  diagnosis,  prognosis,  and  treatment, 
the  author  goes  on  to  describe  his  experiments.  These,  briefly 
stated,  were  as  follows : — 

^  Contribution  d  Vttude  cliniqv£  et  expirimentale  du  Phenomene  Respiratoire  de 
Cheyne-Stokes.    GenSve,  1881. 


1889.]  PHENOMENA  IN  CHEYNE-STOKES  RESPIRATION.  1021 

1.  Pressure  on  the  medulla,  which  caused  phenomena  somewhat 
resembling  those  of  Cheyne-Stokes  respiration. 

2.  Compression  of  the  arteries  supplying  the  brain,  which  pro- 
duced effects  distantly  resembling  Cheyne-Stokes  breathing,  but 
not  presenting  a  regular  ascending  and  descending  type,  or  corre- 
sponding in  time  to  the  intermittent  compression. 

3.  Injection  of  morphine,  with  or  without  subsequent  adminis- 
tration of  chloroform,  giving  results  closely  resembling  Cheyne- 
Stokes  breathing. 

4.  Injection  of  carbonate  of  ammonium  and  kreatin,  with  or 
without  previous  nephrotomy,  producing  respiratory  pauses  and 
spasms  in  no  way  comparable  to  Cheyne-Stokes  breathing. 

5.  Various  operations  on  frogs,  leading  to  many  phenomena  like 
those  of  Cheyne-Stokes  breathing. 

This  leads  to  the  description  of  ten  cases  personally  observed  by 
the  author,  and  of  another  communicated  to  him  by  Dr  Mermod. 
Summarized  as  shortly  as  possible,  these  cases  were  as  follows: — (1), 
Chronic  renal  disease  in  a  man,  aged  60  ;  (2),  Hasmophylia  in  a  boy, 
aged  3^;  (3),  Chronic  renal  disease  in  a  man,  aged  48;  (4),  Chronic 
renal  disease  in  a  woman,  aged  84 ;  (5),  Chronic  renal  disease  in  a 
man,  aged  77 ;  (6),  Chronic  renal  disease  in  a  woman,  aged  41;  (7), 
Atheroma  and  chronic  renal  disease  in  a  man,  aged  70;  (8),  Clironic 
renal  disease  in  a  man,  aged  74;  (9),  Atheroma  with  thrombosis  of  the 
carotid  artery  and  cerebral  embolism  in  a  man,  aged  65;  (10),  Chronic 
renal  disease  in  a  man,  aged  50;  and  (11),  Mitral  and  aortic  disease, 
with  consecutive  renal  affection,  in  a  man,  aged  70.  Some  of  these 
cases  presented  the  fully  developed  phenomena  of  Cheyne-Stokes 
breathing  with  its  associated  symptoms;  others  were  simply 
accompanied  by  the  respiratory  changes  alone. 

The  author  concludes  this  excellent  dissertation  by  drawing  up 
the  following  conclusions : — 

1.  The  fundamental  condition  causing  the  phenomenon  is  dimin- 
ished excitability  of  the  respiratory  centre. 

2.  This  diminislied  excitability  is  most  commonly  the  con- 
sequence of  some  obstacle  to  the  supply  of  blood  to  the  medulla, 
such  as  some  change  in  the  vascular  walls,  some  cardiac  afifection, 
or  some  compression  of  the  medulla. 

3.  This  diminished  excitability  may  also  be  caused  by  haemor- 
rhages and  poisons. 

4.  The  apnoea  is  not  produced  by  excess  of  oxygen,  but  by 
exhaustion  of  the  respiratory  centre. 

5.  The  peculiar  characters  of  the  hyperpnoea  are  caused  by  the 
gradually  increasing  recovery  of  the  centre  and  by  progressive 
diminution  of  its  excitability. 

6.  The  role  attributed  to  spasm  of  the  vessels  in  the  causation 
of  the  symptom  does  not  appear  to  rest  on  sufficiently  certain 
facts. 

7.  The  frequency  with  which  the  symptom  is  associated  with 


1022  DR  G.   A.   GIBSON  ON  THE  {MAY 

chronic  renal  disease  depends  less  on  the  kidney  affection  than  on 
the  vascular  degeneration  with  which  it  is  associated.  The  urinary- 
troubles  only  play  a  secondary  part,  by  producing  cardiac  or 
pulmonary  affections,  and  by  altering  the  state  of  the  blood.  The 
development  of  the  phenomenon  in  these  cases  does  not  seem  to 
have  a  direct  relation  to  an  intoxication  by  extractive  matters  or 
ammonium  carbonate. 

8.  Occurring  in  very  diverse  conditions  Cheyne-Stokes  breathing 
has  no  precise  diagnostic  value. 

9.  The  intermittent  appearance  of  the  phenomenon  and  its  com- 
plete disappearance  prove  that  it  does  not  depend  on  a  profound 
alteration  in  the  structure  of  the  respiratory  centre. 

10.  Although  most  commonly  the  precursor  of  a  speedy  fatal 
issue,  the  symptom  may  be  compatible  with  survival  for  a  long 
period. 

11.  Without  extolling  narcotics  it  may  be  stated  that  in  cases  of 
Cheyne-Stokes  respiration  they  may  render  good  service,  and  that 
their  dangers  have  been  considerably  exaggerated. 

Langer^  describes  a  case  of  tumour  of  the  pons  in  a  young 
woman,  where  Cheyne-Stokes  respiration  was  present  in  its  typical 
development. 

In  an  investigation  into  the  periodic  breathing  of  frogs,  Langen- 
dorff  and  Siebert^  note  that  after  the  blood  supply  to  the  medulla 
lias  been  cut  off,  frogs  show  a  periodic  rhythm  of  respiration,  and 
that  the  result  is  the  same,  whether  the  blood  supply  is  cut 
off  by  tying  the  aorta  or  bleeding  the  animal,  while  substitution 
of  a  physiological  solution  of  common  salt  for  the  blood  sometimes 
allows  the  ordinary  type  of  respiration  to  continue,  but  often 
modifies  it  in  various  ways.  Stimulation  of  the  skin  during  the 
pauses  between  the  periods  of  breathing  causes  the  appearance  of 
a  group  of  respirations.  They  regard  periodic  respiration  as 
conditioned  by  disturbance  of  irritability  induced  by  modifications 
of  nutrition.  The  ascending  character  they  attribute  to  the 
gradual  disappearance  of  exhaustion — the  descending  phase  is 
not  so  often  seen. 

Langendorff^  has  further  observed  periodic  respiration  in  frogs 
after  the  administration  of  muscarine,  which  he  regards  as  acting 
directly  on  the  respiratory  centre,  causing  a  true  disturbance  of 
its  nutrition.  In  the  same  paper  he  describes  periodic  respiration 
caused  by  digitalin,  which  he  attributes  to  the  influence  of  the 
drug  on  the  heart,  as  the  respiratory  phenomena  only  appear 
when  the  heart  is  brought  nearly  into  the  condition  of  stand  still. 

Sansom^  is  of  opinion  "that  the  respiratory  nerve  centre  is 

1  Medizinische  Jahrbilcher  der  k.  k.  Gesellschaft  der  Aerzte  in  Wien,  S.  515, 1881. 

2  Archivfiir  Physiologie,  Jahrgang  1881,  S.  241. 

3  Ibid.,  Jahrgang  1881,  S.  331. 

*  Manual  of  the  Physical  Diagnosis  of  Diseases  of  the  Heart.  Third  edition, 
p.  38, 1881.  i>  J  J  , 


1889.]  PHENOMENA  IN  CHEYNE-STOKES  RESPIRATION.  1023 

directly  influenced — that  it  suffers  a  paralytic  lesion,  and  so  its 
irritability  is  impaired,"  but  adds  that  "it  may  be  doubted  whether, 
in  some  cases,  the  symptom  may  not  be  initiated  by  disease  of 
the  heart-muscle  itself." 

Davy^  describes  the  case  of  a  man,  aged  70,  subject  to  attacks 
of  cardiac  asthma,  who  at  times  presented  characteristic  breathing 
of  this  type. 

Langer^  commences  an  excellent  contribution  to  the  study  of 
this  subject  by  defining  the  symptom  and  describing  the  pheno- 
mena with  which  it  is  so  often  associated,  after  which  he  refers  to 
modifications  in  its  type,  and  states  that  his  observations  lead  him 
to  agree  with  Eosenbach  that  true  Cheyne-Stokes  respiration  may 
occur  in  cerebral  cases.  He  afterwards  analyses  the  various 
phenomena,  especially  dwelling  on  those  connected  with  the  state 
of  the  consciousness,  the  muscular  condition,  the  changes  in  the 
eyes,  and  the  circulatory  modifications.  All  of  these  he  holds  to 
be  explicable  by  one  of  two  possibilities — either  that  the  excita- 
bility of  the  centres  increases  and  diminishes,  or  that  the  stimuli 
vary  while  the  excitability  remains  constant.  This  leads  him  to 
mention  the  rival  theories  of  Filehne  and  Eosenbach. 

He  then  narrates  the  case  of  a  mason,  aged  29,  suffering  from 
chronic  Bright's  disease.  In  this  case  Cheyne-Stokes  breathing 
was  developed  with  changes  in  the  condition  of  the  consciousness 
and  in  the  movements  of  the  eyeballs,  but  without  any  alteration 
in  the  pupils  corresponding  to  the  two  phases  of  the  breathing. 
After  this  had  continued  for  twenty-four  hours,  periodic  changes 
in  the  condition  of  the  circulation  showed  themselves,  the  tension 
of  the  pulse  rising,  and  its  rate  sinking  with  the  ascending  phase 
of  the  respiration,  and  the  converse  taking  place  during  the 
descending  phase  and  the  subsequent  pause.  After  these  condi- 
tions had  existed  for  two  days  a  change  ensued,  and  on  account  of 
an  alteration  in  the  relation  of  the  pulse  and  respiration,  it  often 
happened  that  the  highest  tension  and  lowest  rate  of  the  former 
coincided  with  a  pause  of  the  latter. 

The  author  regards  this  observation  as  giving  support  to  the 
theory  of  Eosenbach,  to  which,  as  well  as  to  the  work  of  Solokow 
and  Luchsinger,  and  Hein,  he  refers  in  concluding  his  paper. 

De  Witt^  records  a  case  in  which  the  patient,  an  elderly  man, 
fell  down  and  probably  struck  the  back  of  his  head.  He  became 
unconscious,  and  developed  long  pauses  in  the  breathing.  It  is 
open  to  question  whether  this  case  may  be  regarded  as  having  any 
close  connexion  with  the  subject  under  discussion. 

Paterson*  narrates  the  case  of  a  middle-aged  gentleman, 
suffering   from   Bright's    disease,   who   presented   the   symptoms 

1  Cincinnati  Lancet  and  Clinic.     New  series.     Vol.  viii.  p.  492,  1882. 

2  Wiener  medizinische  Presse,  xxiii.  Jahrgang,  S.  1253  u.  1289,  1882. 

3  Cincinnati  Lancet  and  Clinic.     New  series.     Vol.  ix.  p.  2CK),  1882. 
♦  Lancet,  vol.  i.  for  1883,  p.  121. 


1024  DR  G.  A.  GIBSON  ON  THE  [MAY 

of  Clieyiie-Stokes  respiration,  which  he  is  inclined  to  attribute 
to  cardiac  hypertrophy  and  puhnonary  oedema,  acting  injuriously 
on  the  medulla  oblongata. 

Knoll,^  in  a  contribution  to  the  study  of  irregular  and  periodic 
breathing,  distinguishes  between  spontaneous  alterations  in  the  state 
of  the  respiratory  centre  and  changes  which  are  produced  reflexly. 
He  liolds  the  latter  class  to  be  very  much  more  extensive  than  the 
former,  traces  out  the  mode  of  origin  in  both,  and  gives  examples 
of  each.  Amongst  periodic  breathing  the  author  dwells  on  that  of 
the  "meningitic  type"  of  Biot,  which  he  holds  to  be  dependent  on 
a  sinking  of  the  irritability  of  the  respiratory  centre  rather  than 
on  a  stimulus  caused  by  the  blood,  leaving  it  in  doubt,  however, 
whether  other  factors  may  not  also  be  concerned  in  its  production. 
He  also  devotes  some  remarks  to  Cheyne-Stokes  phenomenon, 
mentioning  the  various  methods  by  means  of  which  appearances 
more  or  less  like  it  may  be  produced,  and  concluding  that  he 
would  not  be  justified  in  regarding  the  symptom  as  a  reflex 
phenomenon  of  deeply  depressed  irritability  of  the  respiratory 
centre,  in  opposition  to  any  theory  of  blood  stimulus. 

Fano,^  in  the  course  of  some  investigations  on  the  red  blood- 
corpuscles,  observed  that  after  removing  the  heart  from  a  tortoise 
the  breathing  persisted,  not  indeed  with  its  previous  regularity, 
but  in  a  periodic  manner,  the  respirations  being  grouped  together 
and  the  different  groups  separated  by  long  pauses.  This  observa- 
tion, which  he  repeated  more  than  once  with  different  forms  of 
tortoise,  and  which  he  compares  with  the  results  of  Solokow  and 
Luchsinger,  led  him  to  consider  the  origin  of  Cheyne-Stokes 
respiration.  Such  experiments  he  holds  to  have  entirely  over- 
thrown the  theory  of  Filehne,  already  refuted  by  Luciani.  Fano 
proceeds  to  detail  the  methods  which  he  adopted  in  his  investiga- 
tions, and  afterwards  criticises  the  theories  of  Filehne,  Traube, 
Solokow  and  Luchsinger,  Langendorff  and  Siebert,  and  Luciani. 

This  is  followed  by  a  description  of  his  experiments  with 
carbonic  oxide  and  carbonic  acid  gases.  He  found  that  tortoises 
were  able  to  live  and  breathe  for  many  hours  when  in  an  atmo- 
sphere solely  composed  of  either  of  these  gases ;  and  he  concludes 
this  fact  to  be  enough  to  show  that  there  may  be  some  doubt  as 
to  the  production  of  respiratory  movements  by  the  state  of  the 
blood.  Other  experiments,  performed  with  oxygen,  hydrogen,  and 
carbonic  acid,  confirmed  his  conclusions ;  but  at  the  same  tinje,  as 
he  remarks,  made  some  of  the  nervous  functions  involved  even 
more  mysterious  and  difficult  of  explanation. 

The  occurrence  of  Cheyne-Stokes  breathing  in  a  case  of  apoplexy 
of  the  cerebellum,  due  to  degeneration  of  the  cerebellar  arteries, 
has  been  placed  on  record  by  Hurd.^     In  this  case  marked  conges- 

1  Lotos,  neue  Folge,  iii.  u.  iv.  Band,  S.  109,  1883. 

2  Lo  Sperimentale,  tomo  li.  p  561,  1883. 

3  Boston  Medical  and  Surgical  Jotirnal,  vol.  cix.  p.  195,  1883. 


1889.]  PHENOMENA    I.N    CHEYNE-STOKES   RESPIRATION.  1025 

tion  of  the  whole  medulla  oblongata  was  found  at  the  examination 
after  death. 

In  an  exhaustive  article  on  variola,  Zuelzer^  says  of  that  disease 
that  the  respiration  in  the  early  stages  is  usually  hard  and  laboured, 
and  not  infrequently  shows  at  a  later  stage  the  irregularity  of 
the  Cheyne-Stokes  respiration  phenomenon,  which  continues  more 
or  less  regularly  and  distinctly,  until  towards  the  end  in  fatal 
cases  pneumonia  or  pleurisy  appears. 

Puddicombe^  records  a  case  of  apoplexy  occurring  in  a  man, 
aged  64,  who  towards  the  end  of  the  disease,  in  the  last  days  of 
his  life,  developed  Cheyne-Stokes  respiration.  This  characteristic 
form  of  breathing  only  appeared  during  sleep.  The  pauses  could 
be  interrupted  by  strong  stimuli,  but  as  soon  as  these  ceased 
the  patient  again  fell  into  the  condition  of  apnoea.  Drugs  which 
increased  the  tendency  to  sleep  made  the  patient  worse  instead  of 
better.  The  effect  of  nitrite  of  amyl  is  worthy  of  note.  "  Nitrite 
of  amyl,"  says  the  author,  "  on  being  held  to.  his  nostrils,  stopped 
the  symptoms  temporarily,  but  only  by  causing  him  to  wake  up, 
which  he  invariably  did  after  it  had  been  held  to  his  nose  for 
seven  or  eight  seconds." 

Dunin^  describes  three  cases  in  which  Cheyne-Stokes  respiration 
was  present,  two  being  in  cerebral  haemorrhage,  and  the  third  in 
enteric  fever.  He  is  of  opinion  that  in  the  last-mentioned  case, 
at  any  rate,  the  cause  of  the  symptom  was  exhaustion  of  the 
nerve  centres  in  the  medulla. 

Murri,^  after  some  historical  remarks,  considers  the  nature  of 
the  phenomenon  and  the  type  of  breathing  to  be  designated  by 
the  term  Cheyne-Stokes  respiration,  which  leads  him  to  mention 
the  investigations  which  he  had  previously  carried  out.  He  holds 
that  there  is  in  this  condition  a  regular  increase  and  decrease  of 
the  activity  of  the  respiratory  centre  caused  by  a  mechanism  as 
yet  unknown.  This  definition  is  followed  by  a  reference  to  some 
of  the  views  advanced  by  previous  observers,  particularly  Traube, 
Filehne,  Luciani,  Luchsinger  and  Solokow,  Rosenbach,  Lowitt, 
Langer,  Saloz,  and  Fano,  and  this  is  in  turn  succeeded  by  a  descrip- 
tion of  some  of  the  more  important  work  done  by  them,  and  a 
thorough  criticism  of  their  theories. 

Murri  then  turns  to  the  influence  of  stimulants,  and  finds  that 
variations  in  the  amount  of  carbonic  acid  in  the  blood,  as  well  as 
sensory  stimuli,  the  effects  of  coughing,  or  of  changes  in  the  brain 
circulation  from  pressure  on  the  neck,  together  with  the  result  of 
moral  impressions  and  the  exercise  of  the  will,  can  modify  the 
periodic  breathing.      He  thinks  that  the  respiratory  centre  has 

*  Real-Encyclopadie  der  gesammten  HeiVcunde,  xiv.  Band,  S.  393,  1883. 

2  The  Lancet,  vol.  i.  for  1883,  p.  816. 

3  Gazeta  lekarska,  Rzad  2,  torn.  iii.  S.  945,  1883. 

*  Rivista  clinica  di  Bologna,  serie  terza,  tomo  iii.  p.  737,  1883  ;  and  Archives 
italiennes  de  Biologic,  tome  v.  p.  143,  1884. 

EDINBOaGH    MED.    JOURN.,    VOL.    XXXIV. — NO.   XI.  6  O 


1026  mi   G.  A.  GIBSON  ON  THE  [MAY 

several  zones  of  different  degrees  of  excitability  corresponding  to 
different  groups  of  muscles.  In  health  the  most  sensitive  zone 
responds  promptly  to  stimuli,  and  is  therefore  sufficient  for  the 
function  of  respiration.  If  impaired,  however,  it  needs  stronger 
stimuli,  and  these  rouse  the  other  zones,  causing  dyspncea,  by 
means  of  which  more  oxygen  is  supplied  to  the  blood,  and  there  is 
a  more  rapid  current  in  the  medulla,  leading  to  a  slowing  of  re- 
spiration which  ends  in  the  pause,  during  which  there  is  again  an 
accumulation  of  carbonic  acid  and  a  repetition  of  the  cycle.  The 
decreasing  or  descending  respirations  are  due  to  the  continuance 
of  activity  after  the  interruption  of  the  stimuli ;  the  dyspncea  is 
caused  by  the  delay  in  the  aeration  of  the  medulla.  It  must  be 
admitted,  as  postulated  by  Traube,  that  the  irritability  of  the 
respiratory  centre  is  impaired  in  order  to  have  the  necessary 
conditions  for  the  development  of  Cheyne-Stokes  respiration,  but 
it  is  unnecessary  that  the  pneumogastric  nerves  should  be  intact. 

Tizzoni^  describes  the  lesions  which  he  observed  in  two  cases 
under  the  care  of  Murri  in  which  Cheyne-Stokes  breathing  was 
a  prominent  symptom.  In  one  of  these,  where  the  primary 
disease  was  a  cardiac  lesion,  there  was  chronic  neuritis  of  the 
trunk  of  the  vagus,  with  sclerosis  and  atrophy  of  the  gray  matter 
of  the  medulla.  In  the  other  case,  where  death  was  caused  by 
renal  disease  and  uremia,  the  vagi  were  healthy,  but  there  were 
inflammatory  changes  in  the  internal  or  median  nucleus  of  the 
vagus  as  well  as  in  the  posterior  nucleus  common  to  the  vagus  and 
spinal  accessory  nerves. 

Bramwell,^  in  his  admirable  and  exhaustive  work  on  cardiac 
diseases,  devotes  considerable  attention  to  Cheyne-Stokes  respira- 
tion as  one  of  the  symptoms  of  circulatory  affections.  After 
describing  its  appearances  and  significance,  he  refers  to  the  con- 
ditions which  may  lead  to  its  development,  and  gives  a  brief 
sketch  of  the  views  of  Traube,  Sansom,  and  Filehne.  This  brings 
him  to  state  the  opinion  which  he  has  been  led  to  form,  and  as  his 
explanation  of  the  phenomenon  is  given  with  equal  lucidity  and 
brevity,  it  will  be  satisfactory  to  quote  his  own  words. 

"The  respiratory  centre  in  the  medulla  oblongata  probably  con- 
sists of  two  parts — one  connected  with  inspiration  (the  inspiratory 
centre),  the  other  with  expiration  (the  expiratory  centre).  Now, 
according  to  Eosenthal  (quoted  by  Dr  M.  Foster),  the  inspiratory 
centre  is  the  seat  of  two  conflicting  forces, — one  tending  to  generate 
inspiratory  impulses  (the  discharging  portion  of  the  inspiratory 
centre,  as  we  may  call  it),  and  the  other  offering  resistance  to  the 
generation  of  these  impulses  (the  restraining  or  inhibiting  portion 
of  the  inspiratory  centre),  the  one  and  the  other  alternately  gaining 
the  victory,  and  thus  leading  to  a  rhythmical  discharge. 

*  Memorie  delV  Accademia  delle  Scienze  di  Bologna,  serie  quarta,  tomo  v.  p. 
331,  1883  ;  and  Archives  italiennes  de  Biologie,  tome  v.  p.  226,  1884. 
2  Diseases  of  the  Heart  and  Thoracic  Aorta,  p.  68.     Edinburgh,  1884. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIKATION.  1027 

"  Further,  we  may  probably  with  truth  suppose  that  the  two 
parts  of  the  inspiratory  centre  are  differently  acted  upon  by  the 
same  stimulus;  venous  blood,  for  instance,  which  excites  the  action 
of  the  discharging  portion,  depresses  the  action  of  the  restraining 
portion,  vice  versd  arterial  blood  depresses  the  action  of  the  dis- 
charging portion,  but  strengthens  the  action  of  the  restraining  part. 

"  Now,  if  we  suppose  that  the  discharging  portion  is  in  a  con- 
dition of  irritable  weakness,  in  which  it  is  more  easily  excited  to 
discharge,  but  in  which  it  tends  to  become  more  speedily  and  more 
completely  exhausted  than  in  health — (or,  better  still  perhaps,  that 
both  portions  of  the  centre  are  in  this  abnormal  condition,  i.e.,  a 
state  of  irritable  weakness),  we  have,  I  conceive,  a  condition  of 
things  which  will  satisfactorily  explain  the  phenomena. 

"  Let  us  suppose,  as  it  is  simpler,  a  case  in  which  the  discharging 
portion  is  in  a  condition  of  irritable  weakness,  the  restraining  por- 
tion remaining  normal.  Starting,  as  we  did  in  considering  Filehne's 
theory,  with  the  end  of  the  period  of  apnoea,  i.e.,  with  the  blood 
in  a  highly  venous  condition,  we  may  suppose  : — 

"  (1.)  That  the  venous  blood  gradually  excites  a  paroxysm  of 
dyspnoea : — Firstly  and  chiefly  by  acting  directly  upon  the  inspira- 
tory centre  itself,  depressing  the  action  of  the  restraining  portion, 
and  arousing  the  action  of  the  discharging  portion,  which  has, 
during  the  stage  of  rest  or  apnoea,  been  gradually  recovering  from 
the  condition  of  exhaustion  occasioned  by  the  excessive  discharge, 
which  produced  the  preceding  paroxysm  of  dyspnoea.  Secondly, 
by  stimulating  the  action  of  the  vaso-motor  centre,  in  consequence 
of  which  the  arterioles  are  contracted,  and  the  supply  of  oxygen 
to  the  respiratory  centre  is  still  further  diminished. 

"  (2.)  That  in  consequence  of  the  excessive  irritahility  of  the 
discharging  portion  of  the  inspiratory  centre,  the  discharges  become 
excessive,  and  a  condition  of  dyspnoea  is  produced. 

"  (3.)  That  in  consequence  of  the  weakness  of  the  discharging 
portion  of  the  inspiratory  centre  it  speedily  becomes  exhausted — 
over-exhausted ;  and  the  dyspnoea  tends  to  subside. 

"  (4.)  That  in  consequence  of  the  excessive  respiratory  efforts 
during  the  paroxysm  of  dyspnoea,  the  blood  (which  was  previously 
venous)  becomes  arterialised ;  stimulation  of  the  discharging  por- 
tion of  the  inspiratory  centre  ceases;  stimulation  of  the  restraining 
portion  is  produced ;  and  in  consequence  of  the  deficient  stimula- 
tion and  over-exhaustion  of  the  discharging  portion,  the  restraining 
portion  has  full  swing,  and  the  condition  of  apnoea  is  produced. 

"  The  arterialised  blood  acts  firstly  and  chiefly  upon  the  inspira- 
tory centre  itself,  strengthening  the  action  of  the  restraining 
portion  and  depressing  the  action  (removing  the  stimulation)  of 
the  discharging  portion ;  secondly,  by  removing  the  stimulation  of 
the  vaso-motor  .centre,  in  consequence  of  which  the  arterioles 
dilate,  and  the  supply  of  oxygen  (arterial  blood)  to  the  respira- 
tory centre  is  still  further  increased. 


1028  DR  G.  A.  GIBSON  ON  THE  [MAY 

"  During  the  stage  of  apnoea  the  discharging  portion,  which  was 
exhausted  by  excessive  action  during  the  period  of  dyspnoea, 
gradually  regains  its  irritability,  and  the  condition  required  for 
its  stimulation,  and  for  the  removal  of  the  control  of  the  restrain- 
ing portion,  viz.,  a  venous  condition  of  the  blood,  is,  in  consequence 
of  the  absence  of  the  respiratory  movements,  gradually  developed. 

"  By  this  theory  we  can,  I  think,  satisfactorily  explain : — 

"  (a.)  The  occurrence  not  only  of  diminished  respiratory  move- 
ments after  the  period  of  dyspnoea,  but  the  complete  arrest  of 
respiration  which  occurs  during  the  stage  of  apnoea — a  point  which 
it  is  difficult  to  explain  by  the  other  theories. 

"  (5.)  The  remarkable  fact  that  the  respiratory  centre  is  at  one 
moment  violently  discharging,  and  at  the  next  in  a  state  of 
absolute  quiescence. 

"  (c.)  That  the  dyspnoea  and  apnoea  follow  one  another  with 
rhythmical  regularity ;  and  that  the  one  condition  gradually  passes 
into  the  other,  and  vice  versd." 

Fano,^  in  reply  to  the  criticism  of  Murri,  defends  the  views 
which  he  previously  advanced,  and  in  turn  criticises  the  theory 
proposed  by  the  latter. 

O'Connell^  mentions  the  occurrence  of  Cheyne-Stokes  respira- 
tion in  the  case  of  a  male  infant  who  died  in  one  of  the  respiratory 
pauses  twelve  hours  after  birth.  No  post-mortem  examination 
was  allowed,  and  the  cause  of  the  symptom  therefore  remained 
unknown. 

Fano^  describes  the  respiration  of  the  alligator  as  not  being 
naturally  periodic,  but  as  assuming  this  character  when  the  sur- 
rounding atmosphere  is  cold.  By  spraying  the  animal  with 
ether,  for  example,  it  was  easy  to  render  the  respiration,  which 
was  regularly  rhythmic  previous  to  the  use  of  cold,  periodic  in 
character. 

Fabian*  gives  an  excellent  critical  survey  of  Cheyne-Stokes 
respiration  in  regard  to  the  various  theories  advanced  to  explain  its 
origin ;  he  gives  the  theory  of  Murri  credit  as  being  the  most 
satisfactory  hitherto  proposed,  and  gives  a  very  good  summary  of 
the  views  of  that  writer. 

Piaggio^  devotes  his  graduation  thesis  to  this  subject.  Beginning 
with  some  introductory  observations,  followed  by  a  brief  historical 
retrospect,  he  gives  a  clinical  study  of  the  phenomenon  and  its 
associated  symptoms,  passes  in  review  the  normal  physiology  of 
the  respiration,  and  concludes  that  it  is  not  the  degree  of  arterializa- 
tion  nor  the  arterial  tension,  nor  the  rapidity  of  the  blood  current, 

^  Lo  Sperirmntale,  anno  xxxviii.,  tomo  liii.  p.  132,  1884. 

*  British  Medical  Journal,  vol.  i.  for  1884,  p.  220. 

'  Lo  Sperimentale,  anno  xxxviii.,  tomo  liii.  p.  233,  1884. 

*  0  zjawisku  oddechow^m  Heyne-StoJcesa.  Matldkovski  Ksiega  pamiethowa 
Hoyerowi,  S.  277,  1884. 

'  Sur  une  nouvelle  TMorie  du  Phe'nomine  Bespiratoire  de  Cheyne-Stokes.  Paris, 
1884. 


1889.]  PHENOMENA   IN    CUEYNE-STOKES   RESPIRATION,  1029 

nor  the  action  of  the  heart  and  lungs,  but  the  cell  itself  that  regulates 
the  amount  of  oxygen  consumed  by  the  organism.  He  supposes 
that  there  are  two  respiratory  centres,  one  of  which  presides  over 
the  respiration  of  the  tissues,  and  controls  the  respiratory  centre  as 
usually  understood.  Passing  on  to  consider  the  pathological 
physiology,  Piaggio  grants  for  the  appearance  of  Cheyne-Stokes 
breathing  a  diminished  excitability  of  these  centres,  and  ex- 
presses his  opinion  that  the  various  circulatory  changes  which 
accompany  the  symptom  are  of  a  compensatory  nature.  He  does 
not  allow  that  the  forced  breathing  is  true  dyspnoea,  and  compares 
it  with  analogous  symptoms  seen  in  hysteria  and  other  nervous 
affections.  After  criticising  some  of  the  most  recent  work  done 
immediately  before  the  appearance  of  his  thesis,  he  sums  up  his 
views,  stating  that  there  is  in  Cheyne-Stokes  respiration  a  constant 
force  whose  intensity  is  invariable  and  subnormal,  and  whose 
source  is  in  the  condition  of  the  tissue,  not  in  the  state  of  the 
blood ;  that  the  tissue  centre  of  respiration  controls  its  subordinate, 
the  automatic  centre  of  respiration,  and  that  this  latter  may  be 
affected  indirectly  through  disturbance  of  its  superior  centre  or  by 
means  of  influences  acting  directly  upon  itself. 

In  an  investigation  into  the  action  of  sulphuretted  hydrogen  on 
the  respiration,  Smirnow^  found  that  when  the  air  breathed  con- 
tained from  one-eighth  to  one-seventh  per  cent,  of  this  substance, 
"a  classical  Cheyne-Stokes  breathing,"  as  he  calls  it,  appeared, 
accompanied  by  variations  in  the  diameter  of  the  pupils,  the 
sensibility  of  the  conjunctiva,  and  the  rate  of  the  pulse.  The 
condition  was  present  as  long  as  the  animal  breathed  the  mixture, 
and  disappeared  when  ordinary  air  was  allowed  to  replace  it.  The 
author  mentions  that  on  the  periodicity  and  ascending  and 
descending  character  of  the  respiratory  movements  section  of  the 
vagi  and  of  both  laryngeal  nerves  had  no  effect.  He  states  that 
the  blood-pressure  fell  during  the  cessation  of  respiration  and  rose 
when  it  recommenced,  while  the  pulse  became  less  frequent  during 
the  pause.  On  dividing  the  vagi  the  change  in  frequency  did  not 
appear,  but  the  falling  of  blood-pressure  remained.  Smirnow  was 
able,  therefore,  to  produce  almost  all  the  features  of  the  Cheyne- 
Stokes  respiration-phenomenon,  and  from  his  study  of  it  he  is  of 
opinion  that  the  periodicity  of  the  breathing  is  only  conditioned 
by  weakness  of  the  respiratory  centre.  He  thinks  that  the 
appearances  presented  by  the  circulation,  pupils,  and  other  organs 
depend  upon  a  synchronous  affection  of  the  other  corresponding 
nerve  centres,  which  is  not  connected  with  the  type  of  the  respira- 
tion. 

Kaufmann^  contributes  a  paper  on  some  artificially  produced 
phenomena  in   Cheyne-Stokes   breathing,  which   he  observed  in 

1  Centralblatt  fiir  die  medicinischen  Wissenschafterif  xxii.  Jahrgang,  S.  641, 
1884. 

2  Prager  medicinische  Wochfinschrift,  ix.  Jahrgang,  S.  344  u.  354,  1884. 


1030  PHENOMENA   IN   CHEYNE-STOKES   RESPIKATION.  [MAY 

the  case  of  a  man,  aged  54,  suffering  from  general  tuberculosis, 
where  it  was  developed  after  the  use  of  chloral  and  morphine. 
The  periodic  breathing  was  accompanied  by  periodic  changes  in 
the  size  of  the  pupils  and  in  the  movements  of  the  eyeballs,  by 
periodic  variations  in  the  state  of  the  intellect,  but  not,  so  far  as 
could  be  made  out  by  means  of  the  finger,  by  any  changes  in  the 
state  of  the  circulation.  Kaufmann  found  that  during  the  pause 
of  the  breathing,  respiration  could  be  excited  by  the  application  of 
cold,  by  striking  the  surface  of  the  body,  by  tickling  the  sole  of 
the  foot,  and  by  speaking  loudly  to  the  patient,  and  he  gives 
tracings  of  the  respiration  showing  these  effects.  These  results 
were  usually  accompanied  by  opening  of  the  eyelids  and  widening 
of  the  pupils.  He  is  of  opinion  that  such  effects  could  not  be 
produced  if  there  were  a  total  absence  of  irritability  of  the 
respiratory  centre  or  a  condition  of  true  apnoea,  and  he  also  thinks 
theories  based  upon  a  conception  of  exhaustion  of  the  centre 
require  the  additional  hypothesis  that  the  increase  of  irritability 
induced  by  external  stimuli  is  so  great  as  to  prevent  the  exhaus- 
tion from  giving  expression  to  itself.  He  comes  to  the  conclusion 
that  much  observation  and  experiment  is  required  before  we  can 
arrive  at  a  satisfactory  solution  of  the  phenomenon. 

Attention  has  recently  been  called  by  Gallois^  to  the  fact  that 
this  type  of  respiratory  rhythm  was  observed  towards  the  close 
of  last  century.  In  a  work  by  Nicolas,  a  physician  of  distinc- 
tion at  Grenoble,  entitled,  Histoire  des  maladies  tpidemiqiies 
qui  ont  rigne  dans  la  province  de  Dauphiny  depuis  Vdnn4e 
1780,  and  published  at  Grenoble  in  1786,  there  is  a  descrip- 
tion of  a  respiratory  phenomenon  which  appears  to  be  iden- 
tical with  Cheyne-Stokes  breathing.  Narrating  the  case  of  a 
general  officer,  aged  81,  suffering  from  a  complication  of  senile 
affections,  he,  after  referring  to  the  state  of  the  pulse  which 
was  extremely  irregular,  describes  the  respiratory  phenomenon  in 
the  following  manner : — "  Mais  ce  qui  etait  bien  plus  extraor- 
dinaire que  cette  irregularity,  c' etait  une  suspension  absolue,  une 
fdriation  des  mouvements  du  poumon  pendant  vingt-cinq  ou 
trente  secondes,  a  chaque  trente-cinqui^me  ou  trente-sixi^me 
respiration ;  alors  le  jeu  de  I'organe  se  r^tablissait  peu  £t  peu,  et 
par  une  gradation  tr^s  sensible,  il  reprenait  son  Anergic  ordinaire, 
pour  cesser  de  nouveau  a  peu  pr^s  a  I'instant  marque." 

It  will  be  observed  that  the  ascending  phase  of  Cheyne-Stokes 
respiration  is  accurately  described  in  the  quotation  just  given,  and 
although  there  is  no  mention  of  a  period  of  descending  respiration, 
it  is  impossible  to  avoid  coming  to  the  conclusion  that  Nicholas 
had  before  him  a  typical  example  of  the  breathing  now  under 
consideration. 

{To  le  continued.) 

1  Jmimal  de  la  Society  de  Medecine  et  de  Pharmacie  de  VIshre,  8me  annee,  p. 
267,  1884. 


188S}.]  CLINICAL   REPOliT   OF   CASE   BY   Mil   MILLER.  1031 

CLINICAL  REPORT  OF  CASE  AT  EDINBURGH  ROYAL 
INFIRMARY. 

Under  the  Care  of  Mr  A.  G.  Miller,  F.  R.C.S.E.,  etc    Reported  by  Dr 
Stoddaet,  House  Surgeon. 

Case  op  Volvulus  of  Sigmoid  Flexure. 

M.  H.,  age  18,  female,  occupation  dressmaker,  admitted  to 
Ward  XXXIII.  3rd  January  1889,  complaining  of  swelling  of 
abdomen  and  pain  in  the  abdomen  and  at  foot  of  the  back. 

Report  extracted  from  Medical  Ward  Case-hook. 

History  of  Present  Illness. — Patient  was  taken  ill  on  New  Year's 
Day.  She  had  often  complained  to  her  mother  for  a  week  before 
of  a  swelling  and  lump  in  her  stomach  just  above  the  region  of  the 
umbilicus.  Her  mother,  however,  was  unable  to  discover  any 
swelling  within  the  abdomen.  The  patient  states  that  several 
times  during  the  week  previous  to  the  onset  of  her  acute  symp- 
toms she  felt  as  she  had  been  accustomed  to  feel  previous  to  her 
monthly  periods,  and  she  thought  that  the  latter,  which  had  been 
absent  for  about  ten  months,  were  coming  on  again.  No  menstrual 
flow,  however,  occurred.  On  Monday,  31st  December,  after  about  a 
week's  constipation,  which  is  a  common  thing  with  her,  her  bowels 
were  freely  moved  twice.  She  had  taken  no  medicine,  but  thinks 
the  two  motions  were  due  to  the  ingestion  of  a  good  deal  of 
cake  with  raisins  during  the  Christmas  week.  The  stools  were 
natural,  she  says.  She  went  to  bed  on  New  Year's  Eve  feeling  as 
well  as  usual.  Having  slept,  she  took  a  good  breakfast — fish,  bread 
and  butter,  and  coffee — on  New  Year's  morning.  About  an  hour 
after  breakfast  she  again  felt  a  lump  and  swelled  sensation  above 
region  of  umbilicus.  The  lump,  she  says,  was  about  the  size  of  her 
fist,  and  lay  in  her  stomach  like  a  heavy  load.  No  pain  was  asso- 
ciated with  it.  In  preparing  to  go  out,  she  noticed  she  was  unable 
to  hook  the  lower  part  of  her  jacket.  In  the  course  of  the  next 
few  hours,  she  states,  the  distension  increased.  The  day  being  a 
holiday,  she  went  down  to  the  Waverley  Market  to  spend  the 
afternoon.  What  she  did  when  she  was  there  was  not  ascertained. 
Towards  the  latter  part  of  the  afternoon  she  was  suddenly  seized 
with  severe  cramping  pain  in  the  abdomen  just  above  the  umbilicus, 
associated  with  pain  in  the  region  of  the  body  of  the  sacrum  ;  at  the 
same  time  she  began  to  vomit  up  a  greenish  watery  fluid.  Half 
doubled  up,  she  managed  to  walk  home,  feeling,  with  a  few  short 
intromissions,  the  pain  all  the  way,  and  vomiting  as  she  went  along. 
When  she  arrived  at  home  she  was  put  to  bed,  and  hot  fomentations 
were  applied.  In  a  short  time  slie  was  so  far  recovered  as  to  be 
able  to  go  to  a  servants'  party  in  the  evening.  She  had  not  been 
there  long,  however,  when  the  pain  again  returned,  along  with  some 
faintness,  which  seems  to  have  been  removed  by  brandy.  She  was 
then  taken  home  and  put  to  bed,  where  she  remained  till  brought 


1032  CLINICAL   REPORT   OF   CASE   BY   MR   MILLER.  [MAY 

to  Hospital.  Tlie  pain  had  few  intermissions  till  admission,  and 
the  vomiting  continued.  A  doctor  saw  her  on  Wednesday,  and 
found  the  abdomen  distended  and  tympanitic;  pain  continued  as 
before,  and  also  the  vomiting.  The  doctor  prescribed  morphia 
muriate,  gr.  ^,  hypodermically,  without,  however,  improving  the 
symptoms  in  the  slightest,  and  on  the  3rd  of  January  she  was  sent 
to  the  Hospital. 

Previous  History. — She  has  never  been  a  very  strong  girl,  but 
has  always  enjoyed  fair  health.  Menstrual  function  has  been  almost 
in  abeyance  for  about  ten  months,  except  that  four  months  ago  there 
was  a  very  slight  return  of  the  flow.  Her  periods  have  always  been 
associated  with  swelling  of  tiie  abdomen,  pain,  and  discomfort,  suffi- 
cient to  send  her  to  bed  for  a  day.  Social  conditions  and  habits 
are  good. 

Family  History. — Fatlier  and  mother  healthy.  One  sister,  to 
whom  she  was  a  twin,  died  at  14  of  consumption.  Otherwise 
history  good. 

Present  State — General  Condition. — Conformation  and  develop- 
ment are  good.  She  is  rather  under  size,  and  slenderly  built. 
General  muscularity  fair.  She  is  confined  to  bed  ;  her  expression 
anxious,  especially  during  spasms  of  pain,  when  the  angles  of  the 
mouth  are  much  drawn  down.  She  lies  with  her  legs  well  drawn 
up,  so  that  her  thighs  are  flexed  on  the  trunk.  Temperature 
varies  from  97"°2  in  the  morning  to  100*°2  in  the  evening. 

Skin,  etc. — Perspires  a  good  deal,  especially  in  the  palms  of  the 
hands.  A  good  deal  of  dry  sordes  on  the  lips  of  patient.  No  other 
eruptions.  No  jaundice.  Cheeks  are  rather  rosy.  No  pallor  of 
mucous  membranes.  No  lividity  or  dropsy.  No  marks  of  scrofula 
or  syphilis.     No  articular  signs  of  rheumatism. 

Digestive  System. — Appetite  gone;  thirst  great;  deglutition  normal. 
Patient  keeps  no  food  on  stomach  ;  no  action  of  bowels  since 
Monday,  31st  December  ;  neither  fseces  nor  flatus  passed  since  then. 
Pain  in  abdomen  nearly  always  present — (1)  as  a  dull  depressing 
pain  in  the  umbilical  region  just  above  umbilicus,  and  (2)  as  a 
similar  pain  in  region  of  body  of  sacrum ;  in  former  region  she 
frequently  has  sharp  spasms,  which  cause  her  great  agony. 
Vomiting,  till  admission,  was  associated  with  pain.  The  matters 
seem  to  have  consisted  of  bilious  fluid  and  any  food  she  may  have 
taken.  From  what  her  mother  says,  there  seems  to  have  been  no 
faecal  vomiting.  Vomiting  not  present  since  admission.  No  gaseous 
eructations,  heartburn,  nor  water  brash.  Tongue  slightly  furred  in 
centre,  rather  red  at  the  sides,  and  rather  dry.  Lips  are  dry,  and 
coated  with  sordes,  but  not  very  markedly  so.  Abdomen  is  rather 
tumid,  but  not  markedly  distended.  The  regions  above  and  below 
the  umbilicus  present  slight  comparative  elevations,  but  on  the 
whole  the  contour  is  rounded,  witiiout  irregularities.  Muscular 
wall  is  tense,  so  that  palpation  is  difficult.  Tlie  rectus  on  each  side 
particularly  hard.  Percussion  gives  a  clear  tympanitic  note  all 
over  the  upper  part  of  abdomen.     The  note  becomes  higher  pitched 


1889.]  CLINICAL   REPORT   OF   CASE   BY   MR   MILLER.  1033 

and  duller  over  the  lower  part  of  the  umbilical  and  hypogastric 
regions.  No  liernia  can  be  discovered.  Digital  examination  of  the 
rectum  gives  negative  results. 

Genito-urinary  System. — Urine  varies  from  28  to  38  ounces,  dark 
amber  in  colour,  of  acid  reaction  ;  deposit  present ;  specific  gravity, 
1033  ;  no  blood,  albumen,  bile,  or  sugar  urates  present.  Other 
systems  normal.  Pulse,  84  to  120  per  minute — regular,  full,  strong, 
distinctly  sudden  ;  tension  between  beats  below  the  average.  Radial 
pulses  equal.  Breathing,  20"30  per  minute,  easy,  but  rather  shal- 
low.    Patient  sleeps  a  good  deal. 

Progress  and  Treatment. — Diet — milk  and  lime-water,  with  ice 
to  suck  ;  soda-water,  to  quench  thirst.  Gave — (1)  I^  Liq.  morph. 
hydroch.,  \-s..  every  three  hours ;  (2)  Hot  fomentations  to  abdomen. 

January  3. — Enema  of  olive  oil  and  beef-tea  given  without  effect ; 
enema  returned.  Patient's  pupils  are  much  contracted,  and  she  is 
evidently  now  experiencing  the  effects  of  morphia  given  before 
admission.  Pain  is  now  gone  ;  she  sleeps  a  good  deal.  Pulse,  84; 
breathing,  20. 

January  A. — Only  \\.  of  morphia  given  yesterday,  owing  to 
patient's  narcotized  condition.  To-day,  however,  pain  returned, 
coming  in  spasms  localized  in  anterior  abdominal  wall  about  um- 
bilicus. Great  pain  experienced  if  any  attempt  at  manipulation  be 
practised.  No  outward  signs  of  spasm  seen  at  night,  the  morphia 
having  been  given  all  day.  Patient  is  now  quite  free  from  pain,  sleeps 
a  good  deal,  and  feels  better.  Palpation  now  shows  much  less  dis- 
tension of  the  abdominal  wall,  and  it  is  less  tense.  Enema  given 
without  effect. 

January  5. — No  enema  given  to-day.  Pulse,  78 ;  steady,  regular, 
less  sudden  than  formerly.  Temperature  fell  to  97"°2  in  morning, 
but  rose  to  100°  in  the  evening.     Abdomen  is  a  little  more  tumid. 

January  6. — This  morning  abdomen  is  still  slightly  tumid  ;  not 
more  so  than  yesterday,  perhaps  a  little  less.  On  palpation  there  is  no 
tenderness  whatever.  Resistance  is  different  on  the  two  sides.  It 
seems  normally  elastic  over  the  whole  of  the  left  side  of  abdomen, 
but  on  the  right  side  there  is  comparative  hardness  from  the  pubic 
bone  upwards  beyond  the  level  of  umbilicus  ;  and  this  is  noticeable 
both  in  the  iliac  and  lumbar  regions.  Patient  has  only  occasionally 
spasms  of  pain. 

January  7. — Rectum  examined  by  Dr  Wyllie  and  found  to  be 
empty.  Dr  Wyllie  felt  with  the  finger  a  resistent  mass  higher  up. 
Dr  Wyllie  was  of  opinion  that  this  was  the  abdominal  contents 
pushed  downwards.  Enema  of  olive  oil  and  gruel  given,  without 
any  passage  of  faeces  or  flatus.  Dr  Croom  examined  patient  to-day. 
Nothing  abnormal  was  found  in  the  pelvis  save  that  the  uterus  was 
pushed  back.  Dr  Croom  thought  that  it  was  due  to  the  pressure  of 
the  distended  bowel  higher  up. 

January  8. — Note  hy  Dr  Wyllie. — Abdomen  as  tight  as  before, 
and  very  little  differentiation  either  by  palpation  or  percussion  can 

EDINBDRGH   MED.  JOURN.,    VOL.  XXXIV. — NO.   XL  6  P 


1034  CLINICAL   REPORT   OF   CASE   BY   MR  MILLER.  [MAY 

be  made  out  as  formerly.  On  the  whole  the  percussion  note  is 
higher,  and  resistance  greater  on  the  right  than  on  the  left  side. 
There  is  a  high-pitched  tympanitis  over  the  region  between  the 
umbilicus  and  pubis.  The  part  of  the  abdomen  where  there  is 
least  resistance  and  most  elastic  resiliency  is  in  tlie  left  iliac  region, 
the  part  immediately  above  it.  Behind  this  region  the  percussion 
note  again  becomes  liigher  over  the  left  lumbar  region.  There  is  a 
second  region,  viz.,  the  right  iliac,  in  which  the  note  is  rather 
clearer  and  lower  than  in  the  middle  line.  Tlie  abdominal  wall  is 
now  distinctly  bulged  out  in  both  lumbar  regions.  No  abdominal 
mappings  during  spasms  of  pain  can  be  seen,  and  very  few  sounds 
heard  during  last  twenty- four  hours.  Dr  Wyllie  heard  and  felt  one 
in  right  iliac  fossa.  Gruel  and  olive  oil  enema  given  again,  but 
returned  as  before.     No  flatus  or  fseces  passed. 

January  9. — Patient  has  been  fed  by  nutrient  enemata  for  two 
days.  Small  amount  of  beef-tea  given  by  the  mouth.  Gruel  and 
olive  oil  enema  given  at  5  A.M.  this  morning ;  no  effect  produced. 
Nutrient  enema  given  at  7  a.m.,  and  immediately  after  she  had 
intense  pain  just  below  the  umbilicus  for  an  hour  and  a  half;  after 
that  she  vomited  thrice.  The  vomited  matters  seemed  to  have 
consisted  of  a  small  quantity  of  beef-tea  taken  by  the  mouth.  At 
8.30  beef-tea  and  brandy  enema  was  returned,  and  pain  ceased. 
11  A.M. — She  is  now  quiet,  and  has  no  pain.  Pulse,  140;  breath- 
ing, 30.  Abdomen  much  swollen,  and  more  tympanitic  than 
yesterday.  2  p.m. — As  the  result  of  a  consultation  between  Dr 
Wyllie  and  Mr  Miller,  it  was  decided,  with  the  consent  of  the 
patient,  to  operate.  Consent  having  been  obtained,  patient  was 
removed  to  Mr  Miller's  ward  at  4  p.m. 

Operation. — Patient  being  put  under  chloroform,  an  incision  was 
made  in  the  middle  line,  extending  from  umbilicus  to  pubis ;  and 
the  various  bleeding  points  being  secured,  the  peritoneum  was  then 
incised.  On  opening  into  the  abdominal  cavity,  a  large  tumour  was 
found  filling  up  the  anterior  part  of  the  cavity.  On  passing  the 
hand  in  and  examining  it,  it  was  found  to  be  the  sigmoid  flexure 
greatly  distended.  On  bringing  out  the  bowel  through  the  incision 
it  was  found  to  be  twisted  on  itself  one  and  a  half  turns,  and 
there  was  a  constriction  at  the  junction  of  the  descending  colon  and 
the  flexure,  and  also  at  the  junction  of  the  flexure  and  the  rectum. 
The  twist  was  undone,  when  a  large  quantity  of  liquid  faeces  and 
flatus  passed  per  anum  at  once ;  but  on  attempting  to  empty  the 
small  intestine,  which  had  become  greatly  distended  with  flatus, 
considerable  difficulty  was  experienced.  This  was  got  over,  how- 
ever, by  fixing  the  caecum  and  gradually  working  the  flatus  towards 
it  by  gentle  pressure  on  the  bowel.  The  bowel  was  then  easily  re- 
turned to  the  abdomen,  and  the  incision  closed  by  deep  and  super- 
ficial stitches.  The  patient  was  then  put  to  bed  at  5.30.  The 
after-treatment  consisted  chiefly  in  keeping  the  patient  under  the 
influence  of  morphia,  giving  stimulants — chiefly  brandy  and  stro- 
phanthus— and  keeping  up  patient's  strength  by  nutrient  enemata. 


1889.]  CLINICAL   REPORT   OF   CASE   BY   MR   MILLER.  1035 

The  wound  was  dressed  on  the  lltli  January,  looking  very  well  and 
healing. 

Patient  went  on  very  well  till  about  10  o'clock  on  the  even- 
ing of  the  11th,  when  she  suddenly  began  to  cry  out  and  com- 
plain of"  pain  in  lower  part  of  abdomen.  Then  her  pulse  became 
weaker,  temperature  fell  quickly,  breathing  became  laboured,  and 
frequency  of  respiration  increased.  She  continued  screaming  inter- 
mittently, and  became  more  and  more  collapsed,  until  10.30,  when 
she  died.  Wiienever  these  signs  showed  themselves  brandy  was 
administered  by  the  mouth,  5j.  of  sulphuric  ether  hypodermically, 
and  ^  gr.  of  morphia  also  hypodermically;  and  ITLv.  of  strophanthus 
twice  by  the  mouth. 

Jan.  13. —  Post-mortem  Examination. — No  evidence  of  acute 
peritonitis.  Sigmoid  flexure  greatly  enlarged  and  distended  with 
flatus,  occupying  the  greater  part  of  the  surface  of  the  abdominal 
cavity  anteriorly,  and  pressing  backwards  principally  in  the  left 
iliac  and  lumbar  regions,  so  as  to  flatten  and  compress  the  descend- 
ing colon.  This  doubling  back  of  the  sigmoid  had  caused  com- 
plete obstruction  once  more.  On  removal  of  the  sigmoid  flexure 
with  part  of  the  rectum  and  part  of  the  colon,  it  was  seen  that  the 
lumen  of  the  bowel  had  become  much  contracted  at  the  junction  of 
the  flexure  with  the  colon,  and  that  (from  doubling  in  of  the  wall 
of  the  gut)  a  stricture  had  commenced  to  form  at  the  junction  of 
the  flexure  with  the  rectum. 

Remarks  hy  Mr  A.  G.  Miller. — 1.  The  volvulus  had  been  brought 
about  by  the  following  causes: — Constipation,  consequent  enlarge- 
ment and  elongation  of  sigmoid  flexure,  narrowing  of  both  origin 
and  termination  of  flexure  (which  were  very  close  together),  dis- 
tension with  flatus,  causing  straining  at  neck  of  loop,  and  so  favouring 
volvulus  (see  Treves  on  Intestinal  Obstruction,  p.  136,  diagram). 

2.  Colotomy  (lumbar)  would  have  relieved  this  patient  more 
quickly  and  safely,  and  in  time  the  volvulus  might  have  undone 
itself. 

3.  The  recurrence  of  obstruction  was  due  to  distension  of  the 
flexure  by  flatus.  Might  this  not  have  been  prevented  by  the 
administration  of  laxatives  rather  than  morphia  ? 


I^ait  ^ecouti. 


REVIEWS. 

Lectures  on  BrigMs  Disease.     By  Robert   Saundby,  M.D.  Ed. 
Pp.  290.     Bristol :  John  Wright  &  Co. :  1889. 

This  is  a  nice,  handy  little  book  on  the  subject  of  which  it  treats, 
which  it  is  a  mistake  to  call  Bright's  disease,  or  even  Bright's 
diseases.  Bright  only  described  one  disease,  and  this  book  treats 
of  several.  Lectures  on  albuminuria,  its  significance  and  treat- 
ment, would  more  accurately  describe  its  contents.     It  is  a  book 


1036  LECTUKES   ON   BRIGHT'S   DISEASE,   ETC.  [xMAY 

which  no  practitioner  should  be  without,  as  though  it  is  so  concise, 
yet  there  is  no  subject  connected  with  albuminuria  on  which  the 
most  recent  information  is  not  to  be  had,  together  with  a  very  full 
bibliography  of  all  recent  works  on  each  branch  of  the  subject, 
which  those  desirous  of  fuller  information  may  consult.  And  what 
is  of  most  importance  to  the  student,  this  bibliography  has  not 
been  constructed  from  a  library  catalogue,  but  every  work  has 
evidently  been  well  read  and  studied  by  the  author,  and  is  so 
referred  to  in  the  text  that  the  student  M'ill  have  no  difficulty  in 
selecting  the  treatises  that  will  be  useful  to  him  in  his  inquiries. 
Saundby  is  rather  heterodox  in  his  views  as  to  tiie  importance  of 
albuminuria  as  a  mere  symptom,  and  he  differs  in  his  pathology 
from  those  whom  we  in  Edinburgh  have  been  accustomed  to  regard 
as  authorities  on  albuminuria.  But  there  is  no  ambiguity  in  regard 
to  his  opinions,  which  are  enunciated  with  as  much  clearness  and 
distinctness  as  brevity.  It  w^ould  be  difficult  to  point  out  another 
work  in  wiiich  the  history,  classification,  and  etiology  of  albumin- 
uria is  comprised  in  fifteen  pages ;  and  yet  no  one,  we  think,  could 
rise  from  the  perusal  of  these  fifteen  pages  without  having  acquired 
clearer  and  more  distinct  views  of  the  diffiirent  pathological 
theories  that  have  been  propounded  to  account  for  the  various 
forms  of  kidney  disease  from  the  days  of  Bright  down  to  the 
present  time.  And  yet  these  theories  are  so  concisely  described 
that  no  one,  not  in  his  dotage,  is  ever  likely  again  to  forget  them. 
To  us  in  Edinburgh  it  appears  somewhat  strange  to  have  kidney 
diseases  divided,  not  into  three  forms — to  that  we  are  accustomed — 
but  into  three  such  forms,  as  Febrile  nephritis,  Toxsemic  or  Lithaemic 
nephritis,  and  Obstructive  nephritis.  And  it  astonishes  as  well  as 
perplexes  us  to  find  our  old  friend,  the  waxy  kidney,  described  as 
a  febrile  nephritis,  ''  a  chronic  nephritis  occurring  in  chronic 
pyrexial  diseases."  In  his  pathology  Saundby  is  a  follower  of 
Rosenstein,  to  which  he  says  all  latter-day  pathology  is  tending. 
This  may  be  true,  though  we  may  be  permitted  to  doubt  it.  We 
do  not  and  cannot  agree  with  the  pathology  enunciated ;  never- 
theless, we  have  great  pleasure  in  recommending  this  book  as  a 
most  handy  and  useful  book  for  the  consulting-room,  one  which 
may  be  picked  up  and  referred  to  on  any  subject  connected  with 
the  diagnosis  and  treatment  of  albuminuria,  with  the  certainty  of 
obtaining  the  most  recent  information  regarding  it  It  is  beauti- 
fully printed,  and  the  illustrations  are  distinct  and  accurate.  It  is 
altogether  a  work  of  which  both  author  and  publisher  may  be 
proud  as  a  work  of  art ;  a  few  more  years  will  fix  more  definitely 
than  we  at  present  can  its  position  as  a  work  of  science. 


J%e  Skin  Diseases  of  Infancy  andi  Early  Life.    By  C.  M.  Campbell, 
M.D.,  CM.  Edin.     London :  Bailli^re,  Tindall,  &  Cox :  1889. 

While  there  are  undoubtedly  some  differences  in  the  frequency 
of  occurrence,   the   course   of  the   symptoms,    and   the   mode   of 


1889.]  THE   SKIN   DISEASES   OF   INFANCY,   ETC.  1037 

management  of  skin  diseases  in  the  case  of  children  as  contrasted 
with  adults,  it  is  somewhat  questionable  if  these  are  sufficient  to 
justify  their  treatment  in  a  special  volume.  Dr  Campbell  thinks 
that  they  do  present  certain  features  which  entitle  them  to  be 
studied  clinically  by  themselves.  Some  statements  volunteered 
are  highly  conjectural,  as  that  the  suppuration  in  acne  may  be  due 
to  the  death  of  a  demodex  folliculorum  within  the  follicle  (pp.  124, 
159) ;  or  questionable,  as  that  a  hair  once  attacked  by  the  Achorion 
is  irredeemably  destroyed ;  or  etymologically  incorrect,  as  spelling 
Xeroderma,  Zeroderma.  One  remark  under  eczema  is  happy,  if  not 
new, "  In  some  subjects  the  epidermis  seems  scarcely  able  to  bal- 
ance and  control  the  normal  blood-pressure,  and  to  be  constantly 
breaking  down  under  it. "  The  volume  is  easy  to  read,  and  if  we 
have  not  discovered  any  novel  features,  or  indeed  any  marked 
originality  at  all,  yet  the  matter,  so  far  as  it  goes,  may  be  described 
as  sound.  It  is,  however,  the  slightness  and  sketchiness  with  which 
the  ailments  treated  of  are  handled  which  constitutes  our  gravest 
objection.  We  fear  the  busy  family  attendant,  for  whose  use  it  is 
said  to  be  mainly  intended,  will  in  the  end  have  to  resort  to  some 
larger  and  fuller  treatise  to  find  precisely  what  he  wants  when  in 
difficulty  ;  and  his  search,  in  the  case  of  Dr  Campbell's  book,  is  not 
rendered  easier  by  an  index,  an  omission  to  be  regretted. 


Epitome  of  Surgery.     By  Kidley  Dale,  M.D.,  M.E.C.S.E.,  etc. 
London :  H.  K.  Lewis :  1889. 

A  BOOK  of  nearly  500  pages.  Contains,  in  a  readable  form,  a 
vast  amount  of  information  compressed  into  a  wonderfully  small 
space.  A  single  sentence  out  of  Dr  Dale's  preface  describes  its 
scope  and  object,  "  While  written  primarily  for  the  student,  the 
work  will  perhaps  also  be  of  some  service  to  the  practising  surgeon 
who  may  wish  to  refresh  his  memory  on  certain  points,  and  for 
which  purpose  the  book  may  afford  a  ready  means  of  reference." 
All  these  objects  have  been  kept  well  in  view.  The  student  will 
find  the  book  a  convenient,  and  fortunately,  so  far  as  we  have 
examined  it,  a  safe  "  crammer."  The  excellent  and  full  index  will 
enable  the  practitioner  to  refer  easily  without  having  to  consult 
many  or  expensive  works.  Dr  Dale,  apparently,  has  used  his 
"  twelve  years  experience  "  as  a  grinder  to  good  purpose,  and  has 
produced  a  book  that  ought  to  be  well  appreciated  by  those  for 
whom  it  has  been  written. 


Treatise  on  the  Diseases  of  Women,  for  the  use  of  Students  and 
Practitioners.  By  Alexander  J.  C.  Skene,  Si.D.,  Brooklyn. 
With  251  Engravings  and  9  Chromo-lithographs.  London  :  H. 
K.  Lewis :  1889. 

"  The  history  of  Gynaecology  and  the  discussion  of  all  unsettled 


1038  TKEATISE   ON   THE  DISEASES   OF   WOMEN,   ETC.  [mAY 

questions  have  been  omitted.  ...  To  tlie  medical  student  his- 
tory lias  no  value  until  he  has  mastered  the  rudiments  of  the  Science 
and  Art,  and  the  practitioner  can  find  in  the  works  of  reference  all 
the  iiistorical  facts  which  he  may  seek."  Having  thus  in  his  pre- 
face cleared  the  way,  the  author  presents  us  with  an  eminently 
practical  and  useful  treatise,  whether  for  the  student  or  practitioner. 
Quite  one-third  of  the  book  is  devoted  to  the  diseases  of  the  bladder 
and  urethra,  and  with  a  discoverer's  pardonable  pride  the  urethral 
glands  come  in  for  a  fair  share  of  attention.  Tlie  reader  will  not, 
however,  be  disposed  to  find  fault  with  this  somewhat  undue  pro- 
minence, as  he  will  find  that  this  section  of  the  book  forms  a 
complete,  masterly,  and  valuable  treatise  on  a  class  of  cases  un- 
doubtedly most  trying  and  difficult  to  treat.  Nor  will  the  remainder 
of  the  book  be  found  of  less  interest  or  utility.  It  is  written  in  an 
attractive  style ;  and  numerous  illustrative  cases  are  introduced, 
which  greatly  serve  to  impress  the  conditions  described  and  the 
treatment  recommended  on  the  attention  of  the  reader.  To 
the  practitioner  the  book  must  prove  of  great  service  as  a  rich 
mine  of  resource  in  the  departments  of  treatment  and  thera- 
peutics. 


Handbook  of  Gynaecological  Operations.  By  Alban  H.  G.  Doran, 
Surgeon  to  Out-Patients,  Samaritan  Free  Hospital.  With  Illus- 
trations.    London:  J.  &  A.  Churchill:  1887. 

In  this  work  the  first  four  chapters  are  devoted  to  the  surgi- 
cal anatomy  of  the  female  pelvic  organs,  the  methods  of  pelvic 
exploration,  instruments  and  appliances.  The  first  two  chap- 
ters closely  resemble  what  is  to  be  found  in  every  text-book 
on  diseases  of  women ;  the  second  two,  on  instruments,  almost 
entirely  refer  to  abdominal  operations.  The  next  chapter,  on 
electrical  apparatus,  is  by  Dr  Stevenson ;  and  after  it  we  find  our- 
selves launched  into  what  seems  to  be  the  main  object  of  the  book 
— the  operation  of  ovariotomy,  including  minute  details  regarding 
everything  connected  therewith,  not  omitting  the  training  of 
ovariotomy  nurses.  Roughly  speaking,  270  out  of  474  pages  of 
the  book  are  devoted  to  abdominal  operations,  while  after  deducting 
the  introductory  chapters  and  the  one  by  Dr  Stevenson,  there 
remain  a  little  over  100,  in  which  are  treated  vaginal  extirpation  of 
the  uterus,  amputation  of  the  cervix,  trachelorraphy,  operations  on 
the  perinasum,  bladder,  and  vagina.  Without  doubt  abdominal 
surgery  is  a  great  matter  nowadays ;  but  surely  in  a  book  of  the 
pretensions  of  the  one  before  us,  professing  to  deal  witli  gynseco- 
logical  operations,  it  should  not  be  given  such  an  undue  preponder- 
ance of  attention.  Apart  from  this,  which  we  consider  a  serious 
fault,  the  work  is  worthy  of  attention  for  the  clear  and  precise 
descriptions  of  the  operations  included  in  it. 


1889.]      TRANSACTIONS  OF  AMEUICAN  GYNECOLOGICAL  SOCIETY.      1039 

Transactions  of  the  American  Qynmcological  Society.     Vol.  XIII., 
for  the  Year  1888.     Philadelphia  :  Wm.  J.  Doonan  :  1888. 

Abstracts  of  the  papers  read  at  the  meeting  of  the  above 
Society  in  1888  have  already  appeared  in  our  pages.  We  now 
welcome  the  full  reports  as  contained  in  the  Transactions,  and 
again  have  to  congratulate  the  American  Society  on  its  vigour,  on 
its  successful  meetings,  and  on  the  valuable  character  of  its  yearly 
volume.  

The  Principles  of  Nursing.  Two  Lectures  delivered  to,  and  pub- 
lished at  the  request  of  the  Ladies'  Class  of  the  St  Andrew's 
Ambulance  Association  (Ayr  Centre).  By  W.  J.  Naismitji, 
M.D.,  F.R.C.S.Ed.  (Exam.),  one  of  the  Lecturers  and  Examiners 
of  the  Association.     Ayr:  1888. 

Dr  Naismith  starts  wisely  by  telling  the  audience  that  it  is 
impossible  to  turn  out  a  competent  nurse  through  the  agency  of  a 
couple  of  evening  meetings  in  a  public  hall,  and  he  is  quite  right. 
Still  the  ladies  who  asked  to  have  these  lectures  reprinted  were 
also  right,  for,  with  a  delicate  touch  of  wit  and  wisdom,  Dr 
Naismith  has  managed,  not  only  to  give  a  good  deal  of  sound 
rules  about  nursing,  but  also  to  take  the  opportunity  of  giving  a 
lay  audience  some  uncommonly  good  advice. 

The  difficulty  of  getting  a  trained  nurse  into  the  house  till  it  is 
too  late  used  to  be  very  great.  It  is  not  so  bad  now;  but 
Dr  Naismith  tells  the  public  when  to  get  a  nurse,  how  to  treat 
her,  and  how  to  help  her.  Many  excellent  domestic  hints  are 
given  :  how  to  mend  a  fire,  to  air  a  room,  to  wash  a  patient,  to 
make  a  bed.  A  very  amusing  but  true  description  is  given  of  the 
offensive  female  friend  who  so  often  tries,  and  sometimes  succeeds, 
in  upsetting  the  comfort  of  every  one  by  injudicious  recommenda- 
tions of  drugs,  diet,  or  doctors.  The  homoeopathic  friend  is 
admirably  hit  off,  and  the  class  of  patients  described  who,  having 
little  to  do,  like  to  have  frequent  doctor's  visits,  and  have  their  daily 
homceopathic  visitor  with  his  granules,  but  when  really  ill,  at  once 
have  a  doctor  to  tend  them,  as  they  call  it,  in  the  ordinary  way. 

There  is  a  delightful  account  of  the  economical  and  far-seeing 
patients  who  preserve  their  half-drunk  mixtures,  which  are  used  on 
the  next  victim  six  months  hence,  and  who  say,  "  We  didn't  think 
of  sending  for  a  doctor,  as  xue  thought  the  illness  was  the  same  as 
Johnnie  had  six  months  ago,  and  that  the  medicine  would  do  for 
Tommy."  Very  wise  advice  is  given  on  the  risk  of  repeating  pre- 
scriptions without  the  doctor's  leave.  He  might  also  have  spoken 
of  the  risk  incurred  by  lending  prescriptions  to  others  on  the  prin- 
ciple of  what  is  sauce  for  the  goose  is  also  sauce  for  the  gander. 
Sick-room  demeanour  is  well  described :  the  mysterious  soft,  let- 
me-dissemble  style  being  contrasted  with  the  noisy  and  loquacious. 
Which  is  worst  ? 


1040  THE   PKINCIPLES   OF   NURSING,   ETC.  [MAY 

A  few  hints  on  domestic  medicines  and  infection  conclude  a 
moat  interesting  and  readable  pamphlet.  One  most  amusing 
example  of  the  difficulty  of  finding  a  new  thing  under  the  sun  is 
seen  in  a  quotation  which  Dr  Naismith  makes  from  Marion  Craw- 
ford :  "  People  consider  as  profound  that  which  they  do  not  under- 
stand." Possibly  Marion  Crawford  may  have  once  read,  Omne 
ignotum  jpro  magnifico. 


Antiseptics:  A  Handbook  for  Nurses.      By  Annie  M.  Hewer,  late 
Hospital  Sister.     London  :  Crosby  Lockwood  &  Son :  1888. 

Some  people,  and  even  some  otherwise  intelligent  medical  men, 
hold  that  a  nurse  should  be  "  kept  in  her  place,"  as  they  call  it, 
and  learn  as  little  as  possible  beyond  her  own  practical  duties.  To 
such  this  little  book  will  be  an  offence.  But  to  those  who  think 
that  a  woman,  presumably  fairly  educated  and  intelligent,  will  take 
a  more  thorough  grasp  of  her  orders  if  she  knows  a  little  of  the 
reason  why  these  orders  are  given  this  book  will  be  welcome.  It 
describes  fairly  and  clearly  the  fundamental  principles  of  sepsis  and 
asepsis ;  the  chemical  substances  used,  and  the  dressings,  the 
nurse's  duties,  and  the  bearing  of  antiseptics,  not  only  on  surgery 
but  on  medicine  and  midwifery.  A  little  knowledge  is  a  danger- 
ous thing,  but  this  kind  will  do  no  harm. 


The  Middlesex  Hospital.    Reports  of  the  Medical,  Surgical,  and  Patho- 
logical Registrars  for  the  year  1887.     London :  H.  K.  Lewis. 

We  have  nothing  but  commendation  for  these  carefully  worked- 
out,  and  hence  valuable  reports  by  the  Medical,  Surgical,  and 
Pathological  Registrars  of  Middlesex  Hospital,  who  are  respectively 
W.  Pasteur,  M.D.,  W.  Roger  Williams,  F.R.C.S.,  and  Leopold 
Hudson,  F.R.C.S.  On  the  medical  side  a  summary  of  six  cases 
of  enteric  fever  is  given  with  an  abstract  of  each,  and  of  the  selected 
cases  of  special  interest  there  are,  among  others,  abstracts  of  seven 
cases  of  carcinoma  of  the  stomach.  On  the  surgical  side  the 
analytical  summaries  are  continued,  and  cover  the  six  years  from 
1882  to  1887  inclusive.  We  have  thus  tabulated  for  comparison 
118  cases  of  cancer  of  the  tongue  and  mouth,  38  cases  of  cancer 
of  the  lip,  51  cases  of  cancer  of  the  rectum,  and  25  cases  of  rodent 
ulcer.  Besides  these  there  are  abstracts  of  many  of  the  more 
important  surgical  cases  treated  in  the  last  year.  The  Pathological 
Registrar  gives,  besides  a  classified  summary  of  the  P.  M.  examina- 
tions, a  brief  abstract  of  236  P.  M.  examinations  made  during  the 
last  year. 

The  record  of  clinical  facts  thus  classified  and  summarized  by 
the  three  Registrars  cannot  fail  to  be  of  service  for  future  reference, 
and  no  doubt  in  time  other  hospitals  will  follow  a  similar  plan. 


1880.]  MORTALITY    OF    DJFFEliENT   COLONIES,   ETC.  1041 

Comparative  View  of  the  Mortality  of  dif event  Colonies  from  certain 
Diseases:  Address  delivered  at  the  International  Medical  Con- 
gress held  at  Melbourne.  By  H.  N.  Maclauuix,  M.D.,  LL.D., 
President  of  the  Board  of  Health,  N.S.W.,  Chairman  of  tiie 
Section  of  Public  Health. 

Dii  Maclaurin  is  to  be  congratulated  on  the  choice  of  a  subject 
for  his  presidential  address,  and  also  on  the  way  in  which  he  has 
handled  it.  He  has  brought  out  many  facts  of  the  deepest  interest 
to  all  sanitarians,  and  touciied  on  several  points  not  only  of  import- 
ance to  the  inhabitants  of  Australasia,  but  also  to  Europeans. 

We  are  surprised  to  find  that  the  large  cities  cannot  show  a  more 
favourable  death-rate  in  regard  to  phthisis  than  many  of  our  large 
towns  in  this  country.  The  rural  districts,  however,  show  a  remark- 
able immunity  from  this  disease,  especially  Western  Australia, 
which  will  compare  with  Egypt  and  other  portions  of  North-West 
Africa. 

In  regard  to  the  prevention  of  phthisis,  Dr  Maclaurin  is  very 
decidedly  of  opinion  that  a  law  ought  to  be  enacted  rendering  penal 
all  trafficking  in  tuberculous  animals  or  their  milk ;  and  in  support 
of  this  he  cites  the  very  small  death-rate  from  consumption  (only 
one  death  from  phthisis  in  three  years  out  of  4000  Jews)  among 
the  Jewish  population,  who,  it  is  said,  discard  all  carcases  with  the 
slightest  blemish  or  taint  of  disease.  This  is  very  striking  evidence, 
and  raises  a  question  which  we  would  suggest  our  own  Registrar- 
General  in  the  approaching  census  might  verify.  Looking  at  the 
high  death-rates  from  diphtheria  and  typhoid  fever,  we  can  heartily 
join  Dr  Maclaurin  in  expressing  the  hope  that  sanitarians  Avill  leave 
no  stone  unturned  in  order  to  lower  the  death-rate  from  preventible 
disease  in  the  colonies. 


The  Student.    Nos.  7,  8,  9. 

We  have  received  three  numbers  of  this  neatly  got  up  little 
magazine.  They  contain  a  series  of  articles  on  the  training  of 
medical  students,  and  though  written  in  an  immature  style,  which 
hardly  does  justice  to  the  common  sense  of  their  contents,  are 
entirely  in  the  right  direction. 

Indeed,  the  whole  tone  of  the  magazine  is  very  good.  While 
containing  the  usual  little  jocular  essays,  juvenile  poems,  and 
facetije,  there  is  a  vein  of  earnestness,  and  a  desire  really  to  learn, 
in  the  minds  of  tiie  contributors.  They  seem  to  be,  as  a  rule, 
medical  students,  and  they  can  appreciate  the  teachers  who  really 
try  to  teach,  and  can  laugh  at  those  whose  chief  aim  is  to  decipher 
ancient  manuscripts,  the  value  of  which  is  maintained  only  by  the 
fact  that  the  teacher  is  also  an  examiner  of  his  hapless  victims. 

We  select  one  of  the  "  Simple  Sayings :"  — 

" was  called  one  night  by  a  brother  practitioner  to  see  a 

EDINBURGH    MKD.    JOURN.,   VOL.    XXXIV. — NO.    XI.  6  Q 


1042  THE   STUDENT,   ETC.  [MAY 

patient  (poor)  with  liim.     When  they  had  been  some  time  in  tlie 

cab, said,  '  I  suppose,  doctor,  you  are  aware  that  my  night  fee 

is  five  guineas?'     *  No,  sir,  I  was  not  aware  ;'  and  leaving  tlie  cab, 

the  doctor  said,  '  Cabman,  drive back  to  his  liouse.'     Puzzle, 

who  paid  the  cab?" 


MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY   OF    EDINBURGH. 

SESSION   LXVIII. — MEETING  VI. 

Wednesday,  20th  February  1889. — Dr  Smith,  President,  in  the  Chair. 

The  President  said, — Gentlemen,  you  are  aware  that  the  Special 
Meeting  of  the  Society  this  evening  is  called  for  the  consideration 
of  a  subject  of  very  great  and  wide-spread  interest  and  importance, 
both  in  a  medical  and  a  legal  point  of  view.     Many  difficulties 
beset  the  medico-legal  aspect  of  the  subject,  and  our  object  now  is 
not  to  bring  forward  individual  cases,  but  rather  to  discuss  the 
general  question,  and  to  aid  in  the  elucidation  of  those  points,  of 
which  there  are  a  considerable  number,  requiring  mature  delibera- 
tion, in  order  to  their  being  safely  and  judiciously  dealt  with  in  any 
legislative  enactment  which  may  be  necessary  upon  this  subject. 
The  matter,  you  are  aware,  has  been  brought  before  the  Secretary 
for  Scotland,  and   a  Bill  in  connexion  with  it  has  been  framed 
by  Mr  Charles  Morton,  W.S.,  the  late  Crown  Agent  for  Scotland. 
The  difficulties  of  which  I  speak,  and  which  will  be  brought  more 
prominently  before  you  this  evening,  are  the  considerations  and 
precautions  which  are  required  in  framing  any  measures  with  the 
view  of  being  adopted  for  the  purposes  of  the  Bill  which  is  pro- 
posed to  be  brought  before  Parliament.     Such  considerations  will 
be  recognised   as   those   attaching   to   the  admission   of  persons 
either  as  voluntary  inmates  or  by  committal  as  compulsory  patients. 
There  are  responsibilities  here  which  must  be  taken  into  account. 
The  next  thing  is  the  detention  of  such  persons,  whether  voluntary 
or  by  committal ;  to  consider  what  powers  are  to  be  conferred  for 
the  detention  of  these  patients,  and  in  whose  hand  these  powers  are 
to  be  vested.     Again,  we  must  take  into  consideration  the  exact 
definition  of  what  constitutes  loss  of  self  control,  of  what  con- 
stitutes inability  to  manage  one's  affairs,  or  even  of  danger  to  self 
or  others ;  and  perhaps  it  might  be  well  to  consider  whether  any 
modifications  are  required  in  these  cases  where  the  inebriate  is  a 
habitual  and  continuous  drunkard,  or  one  of  an  occasional  nature, 
where,  perhaps,  the  lapse  of  months  without  any  mental  aberra- 
tion whatever  takes  place  between  the  outbreaks,  which,  however, 
may  be  serious  at  the  time. 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  1043 

Before  calling  upon  Prof.  Stewart  to  open  the  discussion,  I  wish 
the  Secretary  to  intimate  the  apologies  he  has  received  from  several 
gentlemen  who  are  unable  to  be  present  this  evening,  and  I  should 
like  him  to  read  at  length  some  of  them  which  are  of  considerable 
weight,  such  as  Professor  Sir  Douglas  Maclagan's. 

The  Secretary  (Dr  James  Eitchie)  intimated  apologies  from  the 
following: — Professor  Sir  Douglas  Maclagan,  Professor  Gairdner 
of  Glasgow,  Professor  Muirhead,  Professor  Kirkpatrick,  Dr  Morton, 
President  of  the  Faculty  of  Physicians  and  Surgeons,  Glasgow ; 
The  Solicitor  General,  Sheriff  Ivory,  Sheriff  ^neas  Mackay,  Sheriff 
Guthrie  Smith,  The  Dean  of  Faculty,  Mr  Charles  Morton,  Sir 
Charles  Pearson,  Messrs  Arthur  Alison,  J.  Henderson  Begg,  T. 
D.  Brodie,  Charles  Scott  Dickson,  Charles  J.  Guthrie,  T.  G.  Murray, 
Drs  Alfred  Daniell,  Angus  Fraser,  Aberdeen ;  Samuel  Moore,  and 
Alex.  Robertson,  Glasgow. 

He  stated  that  although  several  of  these  gentlemen  had  expressed 
themselves  very  strongly  in  favour  of  further  legislation  for  the 
care  of  habitual  drunkards,  he  would  read  only  three  of  their  letters. 

Professor  Sir  Douglas  Maclagan  wrote : — "  I  cannot  now  go  into 
details,  but  I  beg  to  express  my  cordial  approval  of  the  principles 
of  Mr  Charles  Morton's  Restorative  Homes  (Scotland)  Bill,  To 
do  any  good  we  require  to  have  complete  power,  under  proper 
legal  restraints,  of  saving  these  wretched  people  from  themselves, 
and  it  appears  to  me  that  the  legal  requirements  are  ample  for 
securing  any  one  against  an  infringement  of  that  which  is,  as 
regards  this  subject,  an  intense  humbug — the  liberty  of  the  subject. 
I  really  have  some  difficulty  in  seeing  who  can  be  injured  by  this 
Bill.  It  cannot  be  the  victim,  him  or  herself,  whom  we  wish  to 
save  from,  ruin — soul,  body,  and  estate.  It  cannot  be  his  or  her 
relatives,  whom  we  wish  to  rescue  from  worry  and  misery.  It 
cannot  be  our  excellent  asylums,  both  chartered  and  private,  of 
which  in  Scotland  we  have  so  much  reason  to  be  proud,  because 
as  the  law  stands  we  cannot  legally  commit  the  habitual  drunkard 
to  their  custody.  Why,  then,  should  not  Parliament  give  us  a 
chance  and  enable  us  to  show,  as  I  am  sure  we  would  do,  that 
with  proper  but  safe  guarded  authority  we  could  save  these  sad 
victims  of  that  which  we  all  recognise  as  a  form  of  disease.  I 
hope  that  the  opinion  of  the  Society  will  be  in  favour  of  extended 
powers,  and  that  the  Bill,  avowedly  tentative,  will  be  confined  to 
Scotland." 

Mr  J.  B.  Balfour,  Q.C.,  wrote : — "  The  subject  is  one  the  interest 
and  importance  of  which  cannot  be  over-estimated.  I  should  be 
very  glad  if  anything  could  be  done  in  the  way  of  legislation  to 
mitigate  so  great  an  evil." 

Professor  Gairdner,  Glasgow,  wrote : — "  I  am  strongly  persuaded 
of  the  absolute  necessity  of  a  change  in  the  law  with  respect  to 
habitual  drunkards." 


1044  MEETINGS   OF   SOCIETIES.  [MAY 

Prof.  Grainger  Stewart  said, — The  subject  which  we  are  to  dis- 
cuss this  evening  belongs  in  a  somewhat  special  way  to  this 
Society.  It  is  more  than  thirty  years  since  Dr  Peddie  formulated 
for  the  profession  and  for  the  public,  in  a  very  able  paper  read  here, 
his  views  as  to  the  necessity  for  legislative  enactments  for  the 
benefit  of  certain  classes  of  inebriates  and  their  families  and  estates. 
In  the  discussion  which  followed,  Sir  Eobert  Christison,  Mr  Murray 
Dunlop,  M.P.,  Prof.  Laycock,  and  others,  took  part ;  and  from  that 
time,  as  well  as  in  some  measure  before  it,  the  members  have  been 
interested  in  the  question.  In  the  opinion  of  the  Council,  the 
present  is  an  appropriate  time  for  renewing  the  discussion ;  for  we 
have  now  had  ten  years'  experience  of  the  working  of  "  The  Habi- 
tual Drunkards  Act,  1879,"  and  by  the  light  of  this  experience  we 
are  in  a  position  to  reconsider  the  question.  Further,  many 
members  of  the  medical  and  legal  professions  in  Edinburgh  have 
had  the  opportunity  of  studying  the  provisions  of  the  Bill,  which 
has  been  prepared  by  a  very  able  and  distinguished  lawyer,  who 
was  for  a  number  of  years,  and  under  several  administrations, 
Crown  Agent  for  Scotland,  in  which  it  is  proposed  to  deal  with  the 
question  on  new  lines.  This  suggested  Bill  is  the  more  deserving 
of  study,  as  it  is  known  that  Government  officials  have  been  care- 
fully considering  its  proposals,  and  the  opinion  has  been  expressed 
in  influential  quarters  that  Mr  Morton's  Bill  would  soon  be  intro- 
duced into  the  House  of  Commons,  for  those  in  authority  had 
expressed  great  sympathy  with  it,  and  their  desire  to  further  it. 
For  these  reasons,  and  because  I  hope  that  there  is  now  a  pretty 
general  consensus  of  opinion  in  favour  of  something  further  of  a 
legislative  nature  being  attempted,  I  have  willingly  complied  with 
the  request  of  the  Council  that  I  should  open  the  discussion  this 
evening. 

I  wish  that  it  had  been  possible  to  have  had  it  brought  forward 
by  Dr  Peddie,  who  has  done  more  to  draw  attention  to  this  subject 
than  any  other  man  in  this  country  or  abroad,  or  by  Sir  Douglas 
Maclagan  or  Sir  Arthur  Mitchell,  whose  large  and  special  experi- 
ence would  have  fitted  them  so  well  to  bring  before  us  the  state  of 
the  question.  I  am  glad  that  although  the  duty  has  fallen  upon 
me,  the  Secretary  has  read  us  the  important  expression  of  opinion 
of  Sir  Douglas  Maclagan,  so  that  he  may  be  said  to  have  taken 
the  first  word  in  our  discussion ;  and  we  have  the  benefit  of  the 
presence  of  Dr  Peddie,  and  of  others  eminently  well  qualified  to 
speak,  and  may  hope  to  hear  their  matured  opinions  this  evening. 

The  difficulties  of  dealing  with  the  topic  are  two,  viz., — first,  that 
the  necessity  for  something  being  done  is  so  obvious  as  scarcely  to 
admit  of  argument  or  illustration;  and,  second,  that  the  devising 
of  suitable  plans  is  beset  on  every  side  with  embarrassing  con- 
siderations. 

The  experience  of  every  medical  practitioner,  of  every  family 
lawyer,  and  of   too   many  of   the    general    public,  supplies    ex- 


1889.]  MEDICO-CHIUURGICAL  SOCIETY   OF   EDIKBUKGH.  1045 

amples  of  intemperance  of  many  kinds.  There  is  the  steady 
tippler,  who  takes  small  quantities  of  alcohol  at  intervals  during 
the  day,  never  getting  intoxicated,  and  yet  certainly  shortening 
his  life  by  such  indulgence.  There  is  the  man  who  gets  drunk 
almost  every  night,  but  keeps  perfectly  steady  and  attends  well  to 
his  work  during  the  day.  There  is  the  convivial  victim  of  intem- 
perance, who  is  sure  to  exceed  on  every  festive  occasion.  There  is 
the  ordinary  case  of  delirium  tremens  or  acute  alcoholism.  There 
is  the  victim  of  chronic  alcoholism  and  of  alcoholic  paralysis. 
There  is,  besides,  the  maniac,  the  monomaniac  of  suspicion,  the 
melancholic,  and  the  general  paralytic,  each  of  whom  may  owe  his 
insanity  to  his  drunken  habits.  But  besides  all  these  there  is  yet 
another  class,  and  it  is  for  them  that  legislation  is  specially  required. 
Sometimes  such  patients  look  wonderfully  well  in  the  intervals  be- 
tween their  attacks.  Sometimes  they  show  all  the  features  of  the 
chronic  alcoholic.  The  face  is  flabby,  sometimes  pale,  sometimes 
with  red  or  coppery  nose  or  cheeks;  the  muscles  are  jerking  and  un- 
steady, the  tongue  is  tremulous  and  furred,  the  throat  is  congested, 
and  the  breath  smells  of  more  or  less  altered  liquor.  The  stomach 
is  frequently  disordered;  the  appetite  poor,  especially  of  a  morning, 
with  a  tendency  to  sickness,  with  vomiting  of  mucus ;  the  bowels 
are  irregular ;  the  liver  is  extended  beyond  its  normal  limits,  con- 
gested, and  rather  tender  on  pressure.  The  heart  acts  with  little 
vigour,  often  too  quickly,  and  sometimes  with  fits  of  irregularity 
or  palpitation.  There  is  a  frequent  tendency  to  clear  the  throat, 
and  some  cough.  The  skin  is  soft,  and  tends  to  perspire ;  the 
urine  is  copious,  sometimes  pale  and  of  low  sp.  gr.,  sometimes 
clouded  with  urates,  or  depositing  uric  acid,  or  showing  some 
albumen.  But  the  nervous  system  is  chiefly  changed.  There  is 
undue  sensitiveness  to  impressions,  jerky  and  unsteady  muscular 
movement,  with  incapacity  for  sustained  exertion.  There  is  a 
liability  to  sudden  flushings  or  pallor,  excessive  dryness  or  excessive 
perspiration  of  skin.  There  is  sleeplessness,  nervous  irritability, 
loss  of  the  faculty  of  concentration,  and  impairment  of  memory ; 
while,  perhaps,  from  time  to  time  after  a  drinking  bout  there  is  a 
regular  attack  of  delirium  tremens  or  epileptiform  convulsions,  or 
of  alcoholic  paralysis,  or  of  mania  a  potu.  But  at  all  events  there 
is  an  insatiable  craving  for  drink,  sometimes  constant,  sometimes 
coming  on  occasionally, — a  craving  which  is  declared  to  be  abso- 
lutely irresistible ;  not  that  the  drinking  necessarily  gives  pleasure, 
but  the  desire  cannot  be  resisted.  No  end  of  cunning  and 
ingenuity  is  manifested  in  the  attempt  to  get  supplies  of  liquor. 
The  moral  nature  becomes  so  debased  as  to  be  absolutely  incapable 
of  distinguishing  truth  from  falsehood ;  the  most  ingenious  tricks 
are  resorted  to,  the  most  unblushing  lies  are  told.  The  patients 
lie  with  a  calm  resoluteness,  assure  one  with  a  pleasant  smile  that 
they  have  never  in  any  degree  exceeded ;  and  they  are  never  put 
out  of  countenance  if   you  draw  the  half  emptied  bottle  from 


1046  MEETINGS   OF   SOCIETIES.  [MAY 

beneath  their  pillow,  or  otherwise  convict  them  of  the  most 
flagrant  untruth.  They  are  liberal  of  promises  in  the  highest 
degree,  are  willing  to  acquiesce  in  any  opinion  which  one  may 
express  to  them.  Instead  of  the  sweet  reasonableness  which  a 
recent  much-lamented  writer  used  to  describe  as  one  of  the  best 
qualities  of  man,  they  have  an  unreasonable  sweetness,  so  far  as 
words  and  promises  go.  Their  manner  is  often  tinged  with  a 
peculiar  sadness.  They  seem  to  contemplate  their  own  careers  with 
a  kind  of  melancholy  complacency.  But  while  such  moods  of  mind 
are  common,  a  great  change  manifests  itself  during  the  drinking 
bout,  or  when  they  are  seeking  for  the  gratification  of  their 
appetite.  Then  they  frequently  get  into  trouble ;  they  steal  or 
otherwise  bring  themselves  within  the  grasp  of  the  law ;  and  some 
patients  of  this  kind  are  constantly  getting  imprisoned  for  longer 
or  shorter  periods.  Mr  Smith,  the  governor  of  the  prison  at  Ripon, 
gave  in  his  evidence  before  the  House  of  Commons  in  1872  some 
statistics  regarding  such  a  case,  whose  history  was  known  to  him 
during  a  period  of  25  years.  The  subject,  who  was  a  woman,  had 
been  17  times  in  Wakefield  jail  for  periods  of  from  3  days  to  3 
weeks,  11  times  in  Leeds  jail,  15  times  in  Northallerton  jail,  15 
times  in  Eipon  jail,  all  for  being  drunk  and  disorderly.  She  was 
thus  imprisoned  58  times ;  and  of  the  25  years  of  which  I  have 
spoken,  spent  5  years  9  months  and  20  days  in  prison.  Dr  Peddie 
told  the  same  Committee  of  the  wife  of  a  respectable  tradesman 
who  had  for  42  years  been  a  habitual  drunkard.  Every  possible 
means  had  been  tried  for  her  cure,  but  without  avail.  She  had 
been  boarded  in  different  parts  of  the  country,  prevented  access  to 
drink,  shut  up  on  different  occasions  in  a  lunatic  asylum,  15  times 
in  different  places  of  shelter  and  refuge,  15  times  convicted  of 
drunkenness  and  disorderly  conduct,  and  sentenced  to  various 
terms  of  imprisonment,  running  from  14  to  60  days,  and  her 
periods  of  imprisonment  had  amounted  in  all  to  778  days,  besides 
200  nights  spent  in  police  cells.  He  told  also  of  a  son  of  this 
woman  who  died  in  prison  at  the  age  of  38.  He  began  to  drink 
when  a  mere  lad,  and  although  quiet  and  amiable  when  sober,  had 
at  times  an  irresistible  impulse  to  drink,  and  then  became  furious 
and  dangerous,  and  much  given  to  thieving.  Thirteen  times  he 
was  convicted  of  being  drunk  and  disorderly,  4  times  for  theft ;  he 
spent  922  days  in  prison,  besides  many  nights  in  the  lock-up  when 
he  was  found  in  the  streets  drunk  and  incapable.  The  great 
special  characteristic,  then,  of  this  form  of  intemperance  is,  that 
the  victim  is  possessed  of  an  irresistible  and  insatiable  craving  for 
liquor ;  it  may  be  constantly,  it  may  be  in  paroxysms  recurring  at 
longer  or  shorter  intervals.  This  craving  must  be  gratified  at  any 
cost;  the  victim  becomes,  as  Dr  Peddie  has  said,  regardless  of 
honour  or  truth,  unaffected  by  appeals  to  reason  or  self-interest, 
by  the  tears  of  affection,  or  by  the  suggestion  of  duty  either  to  God 
or  man. 


1889.]  MKniCO-CHIRUUGICAL   SOCIETY   OF   EDINBURGH.  1047 

A  Committee  of  the  House  of  Commons  defined  the  class  as  in- 
cluding those  who,  notwithstanding  the  plainest  considerations  of 
health,  interest,  and  duty,  are  given  over  to  habits  of  intemperance 
which  render  them  unable  to  control  themselves  and  incapable  of 
managing  their  own  affairs,  or  such  as  to  render  them  dangerous 
to  tliemselves  or  others. 

Now  experience  has  made  it  abundantly  plain  that  little  or 
no  benefit  accrues  from  punitive  confinement  in  jails,  or  from  short 
periods  of  residence  in  asylums  for  the  insane,  or  in  houses  of 
refuge  or  shelter,  while  reason  and  experience  both  lead  us  to 
believe  that  confinement  in  suitable  homes  for  lengthened  periods 
might,  in  a  certain  proportion  of  instances,  effect  a  cure,  especially 
if  the  treatment  were  applied  at  a  comparatively  early  period 
of  the  disease.  The  results  of  experience  have  been  distinctly 
encouraging.  I  am  unable  to  attach  much  importance  to  the  returns 
published  in  regard  to  some  of  the  minor  institutions  in  England, 
as  their  results  surpass  what  we  are  entitled  to  expect.  The 
Government  report  for  the  year  1887  states,  on  the  authority  of 
the  manager,  that  two-thirds  of  the  patients  discharged  from  the 
Westgate-on-Sea  Eetreat  were  permanently  cured ;  also  that  most 
of  those  who  remained  in  Walsall  Retreat  for  twelve  months  did 
well ;  while  the  Hales-Owen  Retreat  showed  a  fair  proportion 
really  cured,  but  results  would  have  been  better  if  patients  had 
placed  themselves  earlier  under  restraint,  and  remained  at  least 
twelve  months.  The  Twickenham  results  are  described  as  more 
than  encouraging.  But  the  returns  of  the  Dalrymple  Home,  in 
which  the  utmost  confidence  is  placed  by  those  well  fitted  to 
judge,  show  that  during  three  and  a  half  years  after  the  open- 
ing of  that  institution  there  were  103  admissions  and  85  dis- 
charges; the  average  period  of  restraint  being  six  and  a  half 
months.  Of  the  85  discharged,  36  are  reported  doing  well, 
2  are  reported  improved,  27  not  improved,  1  insane,  3  dead, 
16  not  heard  from.  I  could  adduce  many  striking  results  from 
some  of  the  American  institutions,  but  shall  ask  you  to  fix  your 
attention  upon  the  facts  which  I  believe  to  be  reliable  and  care- 
fully sifted,  that  of  the  103  admissions  to  the  Dalrymple  Home, 
36,  or  upwards  of  one-third,  are  reported  as  discharged  and  doing 
well.     Such  a  result  is  unmistakably  encouraging. 

Now  let  us  see  what  legal  remedies  have  been  proposed  to  meet 
these  evils.  No  one  has  proposed  to  legislate  for  the  mere  tippler, 
for  the  man  who  occasionally  gets  drunk  upon  convivial  occasions, 
nor  even  for  the  man  who,  like  a  patient  whom  Dr  Skae  described 
to  the  Committee  of  the  House  of  Commons,  is  carried  drunk  to  bed 
every  night,  but  who  is  quite  able  to  do  his  work  during  the  day. 
There  is  no  need  for  legislation  in  regard  to  delirium  tremens  or 
chronic  alcoholism.  The  Lunacy  Laws  provide  with  ample  dis- 
tinctness for  the  cases  of  mania  a  potu  and  the  other  varieties  of 
insanity.     It  is  the  special  form  which  lies  upon  the  borderland 


10-48  MEETINGS   OF   SOCIETIES.  [MAY 

between  drunkenness  the  vice  and  obvious  madness  for  wliich  it 
is  believed  we  might  legislate  with  success.  I  have  no  wish  to 
involve  myself  in  questions  as  to  definition  of  insanity  generally, 
and  of  the  precise  relationships  between  it  and  intemperance,  or 
to  attempt  to  formulate  such  a  definition  of  the  disease  we  are 
now  considering  as  would  satisfy  in  every  theoretical  detail  a 
specialist  or  a  lawyer.  I  appeal  to  those  who  are  experienced 
practitioners  for  confirmation  of  the  statement,  that  many  of  the 
cases  to  which  I  am  referring  are  capable  of  easy  and  definite 
recognition,  and  that  for  practical  purposes  the  definition  which 
I  have  already  quoted  from  the  Eeport  of  the  Committee  of 
the  House  of  Commons  is  quite  sufficient.  If  this  be  accepted, 
what  scheme  of  legislative  enactment  might  be  expected  to  prove 
useful  ?  Dr  Peddie,  in  the  Appendix  to  his  first  paper,  gave  a 
series  of  nine  suggestions,  which  I  shall  summarize  :— 

1.  That  four  establishments,  not  lunatic  asylums,  should  be 
opened  in  Scotland  for  the  reception,  comfort,  and  cure  of  dipso- 
maniacs. 

2.  That  a  board,  consisting  of  a  magistrate,  justice  of  the  peace, 
a  clergyman,  and  a  physician,  should  meet  from  time  to  time  to 
consider  cases,  grant  orders  for  reception  and  discharge,  make 
regular  visits  to  the  establishment  in  order  to  see  that  the  various 
arrangements  for  the  care,  comfort,  and  cure  of  the  inmates  are 
properly  carried  out,  and  in  general  to  consider  all  matters  con- 
nected with  the  proper  working  of  the  scheme. 

3.  That  appeal  should  be  to  the  Lord  Advocate  or  Lunacy  Com- 
mission. 

4.  That  applications  for  protection  and  cure  might  be  made 
voluntarily  by  the  dipsomaniac  himself,  he  undertaking  to  submit 
to  the  rules  of  the  institution  and  remain  as  long  as  the  directors 
think  it  necessary.  Compulsory  restraint  might  be  applied  for  by 
any  friend,  relative,  member  of  the  community,  or  parochial  board, 
or  the  procurator-fiscal  for  the  public  interest. 

5.  Applications  for  compulsory  restraint  should  state  in  the 
petition  to  the  sheriff  the  grounds  on  which  they  are  made. 

6.  That  they  must  be  attested  by  witnesses  and  by  the  medical 
attendant  of  the  individual.  The  sheriff  should  also  require  an 
opinion  from  another  medical  practitioner  appointed  by  himself, 
should  then  transmit  the  evidence  in  writing  to  the  board  of  direc- 
tion for  the  district. 

7.  The  board,  being  satisfied,  should  notify  their  opinion  to  the 
sheriff,  that  he  may  grant  warrant,  and  they  make  arrangement  for 
the  admission  to  the  establishment. 

8.  That  no  warrant  or  certificate  should  be  granted  for  a  shorter 
period  than  six  months  or  longer  than  two  years ;  but  that  the 
friends  might  remove  the  patient  under  certain  restrictions  in  a 
shorter  time,  or  that  the  detention  might,  under  certain  condi- 
tions, be  prolonged. 


1889.]  MEDICO-CHIllURGICAL   SOCIKTY   OF   EDINBUKGH.  1049 

9.  That  no  individual  restrained  under  the  regulations  should 
be  considered  as  altogether  deprived  of  civil  rights. 

But  these  proposals  never  came  under  the  consideration  of 
Parliament. 

In  one  of  the  Lunacy  Acts  provision  is  made  for  the  admission 
of  inebriates  into  lunatic  asylums,  they  consenting  to  enter  and 
submit  to  treatment  for  a  certain  time.  This  provision  is,  in  my 
opinion,  an  important  and  valuable  one.  I  have  in  many  instances 
urged  this  step  upon  the  habitually  intemperate,  and  have  some- 
times induced  them  to  take  advantage  of  the  Statute.  I  am  glad 
to  say  that  I  have  seen  complete  and  apparently  permanent  cures 
effected  in  such  cases,  and  I  can  never  be  otherwise  than  grateful 
to  the  ofificers  of  various  institutions  who  have  been  the  means  of 
rescuing  individuals  from  this  otherwise  hopeless  condition.  Still, 
I  must  admit  that  I  have  found  it  difficult  to  avail  myself  of  this 
provision  of  the  Act,  for  the  patient  himself  and  his  family  often 
shrink  from  the  idea  of  confinement  in  a  lunatic  asylum,  and  from 
the  consequences  that  might  result  to  the  subsequent  position  of 
himself  and  his  family,  and  indeed  it  must  be  admitted  that  the 
arrangement  is  otherwise  unsatisfactory  in  respect  that  it  is  not 
good  for  the  habitual  drinker  to  be  placed  in  the  society  of 
ordinary  lunatics,  and  because  patients  of  this  class  often  prove 
troublesome  and  unsatisfactory  inmates  of  asylums,  interfering  with 
the  working  of  the  institution,  tampering  with  attendants,  and  stir- 
ring up  the  ordinary  patients  to  discontent  and  complaint. 

In  1870  the  late  Dr  Donald  Dalrymple,  M.P.  for  Bath,  intro- 
duced a  Bill  in  the  House  of  Commons  providing  for  the  admis- 
sion of  habitual  drunkards  into  retreats.  This  Bill  provided  for 
the  establishment  of  inebriate  reformatories,  sanctuaries,  or  refuges, 
and  for  the  maintenance  of  habitual  drunkards  therein  to  be  charged 
on  the  rates ;  for  the  establishment  by  Boards  of  Guardians  of  a 
special  place  for  the  treatment  of  habitual  drunkards;  for  the  com- 
mittal of  a  pauper  habitual  drunkard  to  a  retreat,  on  the  produc- 
tion of  two  medical  certificates,  for  a  limited  period ;  and  for  the 
committal,  without  certificate,  of  any  person  committed  for 
drunkenness  three  times  within  six  months.  Admission  might  be 
voluntary  or  compulsory  on  the  request  of  a  near  relation,  friend, 
or  guardian,  or  on  the  certificate  of  two  duly  qualified  medical 
practitioners  and  the  affidavit  or  declaration  of  some  credible 
witness.  This  Bill  did  not  pass;  but  in  1872  a  Committee  of  the 
House  was  appointed  to  inquire  into  the  best  plan  for  the  control 
and  cure  of  habitual  drunkards,  and  they  reported  "  that  there  is 
entire  concurrence  of  all  the  witnesses  in  the  absolute  inadequacy 
of  existing  laws  to  check  drunkenness,  whether  casual  or  constant, 
rendering  it  desirable  that  fresh  legislation  on  the  subject  should 
take  place,  and  that  the  laws  should  be  made  more  simple, 
uniform,  and  stringent.  That  occasional  drunkenness  may,  and 
very  frequently  does,  become  confirmed  and  habitual,  and  soon 

EDINBURGH   MED.    JOURN.,    VOL.    XIXIY. — NO.    XI.  6   R 


1050  MEETINGS   OF   SOCIETIES.  [MAY 

passes  into  the  condition  of  a  disease  uncontrollable  by  the  indi- 
vidual, unless,  indeed,  some  extraneous  influence,  either  punitive 
or  curative,  is  brought  into  play.  That  self-control  is  suspended 
or  annihilated ;  moral  obligations  are  disregarded ;  the  decencies 
of  private  and  the  duties  of  public  life  are  alike  set  at  nought ; 
and  individuals  obey  only  an  overwhelming  craving  for  stimulants, 
to  which  everything  is  sacrificed.  That  this  is  confined  to  no  class, 
condition,  or  sex,  and  hardly  to  any  age.  That  it  is  in  evidence 
that  there  is  a  very  large  amount  of  drunkenness  among  all  classes 
in  both  sexes  which  never  becomes  public,  ....  which  is  probably 
even  a  more  fertile  source  of  misery,  poverty,  and  degradation  than 
that  which  comes  before  the  Police  Courts :  for  this  no  legal  remedy 
exists,  and  without  further  legislation  it  must  go  on  unchecked. 
Legislation  in  such  cases  was  strongly  advocated  by  all  the 
witnesses  before  the  Committee.  That  the  absence  of  all  power  to 
check  the  downward  course  of  a  drunkard,  and  the  urgent  necessity 
of  providing  it,  has  been  dwelt  upon  by  nearly  every  witness,  and 
the  legal  control  of  an  habitual  inebriate,  either  in  a  reformatory 
or  in  a  private  dwelling,  is  recommended,  in  the  belief  that  many 
cases  of  death  resulting  from  intoxication,  including  suicides  and 
homicides,  may  thus  be  prevented.  That  this  power  is  obtained 
easily  at  moderate  cost,  and  free  from  the  danger  of  abuse  and 
undue  infringement  of  personal  liberty,  has  been  stated  in  evid- 
ence by  quotations  from  American  and  Canadian  statutes,  as  well 
as  by  the  witnesses  from  America.  That  it  is  in  evidence,  as  well 
from  those  who  have  conducted  and  are  still  conducting  reforma- 
tories for  inebriates  in  Great  Britain,  as  by  those  who  are 
managers  of  similar  institutions  in  America,  that  sanatoria  or 
inebriate  reformatories  are  producing  considerable  good  in  effect- 
ing amendment  and  cures  in  those  who  have  been  treated  in  them. 
That  the  proportion  of  cures  is  not  larger  is  attributed  by  all  the 
witnesses  to  a  lack  of  power  to  induce  or  to  compel  the  patient  to 
submit  to  treatment  for  a  longer  period — and  that  power  is  asked  for 
by  every  one  who  has  had  or  still  has  charge  of  these  institutions. 
Without  such  a  power  it  appears  that  the  results  must  be  imper- 
fect, disappointing,  and  inadequate  to  the  efforts  made." 

The  Committee  therefore  recommended  that — "  Sanatoria  or 
reformatories  for  those  who,  notwithstanding  the  plainest  con- 
siderations of  health,  interest,  and  duty,  are  given  over  to  habits 
of  intemperance,  so  as  to  render  them  unable  to  control  themselves, 
and  incapable  of  managing  their  own  affairs,  or  such  as  to  render 
them  in  any  way  dangerous  to  themselves  or  others,  should  be 
provided." 

The  Committee  further  recommended  that  these  sanatoria  should 
be  divided  into  two  classes — "  (A.)  for  those  who  are  able  out  of 
their  own  resources,  or  out  of  those  of  their  relations,  to  pay  for 
the  cost  of  their  residence  therein;  these,  whether  promoted  by 
private  enterprise  or  by  associations,  can  be  profitably  and  success- 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF  EDINBURGH.  1051 

fully  conducted ; "  and  "  (B.)  for  those  who  are  unable  to  contri- 
bute or  only  partially,  Sanatoria  must  be  established  by  State  or 
Local  Authorities,  and  at  first  at  their  cost,  though  there  is  good 
reason  to  believe  that  they  can  be  made  wholly  or  partially  self- 
supporting." 

The  Eeport  then  proceeds  as  follows : — "  The  admission  to  these 
institutions  should  be  either  voluntarily  or  by  committal.  In 
either  case  the  persons  entering  should  not  he  allowed  to  leave  except 
under  conditions  to  he  laid  down,  and  the  power  to  pi'event  their 
leaving  should  be  hy  law  conferred  on  the  manager.  Though  prac- 
tically this  power  would  be  seldom  put  in  force,  it  would  he  useless 
to  estahlish  these  institutions  without  it. 

"  The  patients  under  Class  A.  should  be  admitted  either  by  their 
own  act  or  on  the  application  of  their  friends  or  relatives  under 
proper  legal  restriction,  or  by  the  decision  of  a  local  court  of 
inquiry,  established  under  proper  safeguards,  before  which,  on  the 
application  of  a  near  relative  or  guardian,  or  a  parish  or  other  local 
authority,  or  other  authorized  persons,  proof  shall  be  given  that  the 
party  cited  is  unable  to  control  himself,  and  incapable  of  manag- 
ing his  affairs,  or  that  his  habits  are  such  as  to  render  him  danger- 
ous to  himself  or  others  ;  that  this  arises  from  the  abuse  of  alco- 
holic drinks  or  sedatives,  and  he  is  therefore  to  be  deemed  an 
habitual  drunkard. 

"  The  period  of  detention  should  be  fixed  by  the  court  of  inquiry 
or  by  the  magistrates,  but  may  be  curtailed  upon  sufficient  proof 
being  given  that  the  cure  of  the  patient  has  taken  place." 

No  legislation  was  accomplished  in  the  direction  of  the  Com- 
mittee's Eeport  for  seven  years. 

In  1877  Dr  Cameron,  M.P.  for  Glasgow,  brought  in  a  Bill  similar 
to  that  of  the  late  member  for  Bath,  but  leaving  it  to  a  jury  instead 
of  a  magistrate  to  decide  whether  an  individual  for  whose  com- 
pulsory committal  to  a  retreat  application  was  made  was  an 
habitual  drunkard  or  no ;  and  at  last,  in  1879,  after  much  oppo- 
sition, "  The  Habitual  Drunkards  Act"  was  passed,  Dr  Cameron 
having  succeeded  in  piloting  it  through  the  House  of  Commons, 
and  Lord  Shaftesbury  through  the  House  of  Lords.  This  Act 
defines  a  habitual  drunkard  as  a  person  who  not  being  amenable 
to  any  jurisdiction  in  lunacy,  is  notwithstanding,  by  reason  of 
habitual  drinking  of  intoxicating  liquor,  at  times  dangerous  to 
himself,  herself,  or  others,  or  is  incapable  of  managing  himself  or 
herself,  and  his  or  her  affairs.  It  provides  for  voluntary  admis- 
sion only,  and  requires  appearance  before  two  justices  of  the 
peace,  with  other  precautions.  There  are  many  details  of  pre- 
cautions, into  which  it  is  not  necessary  for  me  to  go. 

This  Act  was  at  first  passed  for  a  period  of  ten  years,  but  in  1888 
a  short  Bill  was  introduced  and  passed  into  law  rendering  this 
legislation  permanent,  and  requiring  appearance  before  only  one 
justice  of  the  peace  instead  of  two.     The  main  deficiencies  of 


1052  MEETINGS   OF   SOCIETIES.  [MAY 

this  Act  are  that  the  rules  for  obtaining  admission,  as  at  present 
arranged,  are  not  sufficiently  simple ;  that  there  is  no  power  of 
compulsory  confinement;  that  a  period  of  restraint  sufficiently  pro- 
longed for  the  purpose  cannot  be  obtained,  and  probably  that  the 
restraints  are  not  sufficiently  complete.  Such  is  the  present  state 
of  legislation  on  the  matter, 

Mr  Morton's  Bill  is  framed  on  the  lines  recommended  by 
the  Select  Committee  of  1872,  but  proposes  to  deal  only  with 
the  case  of  persons  who  are  able  to  pay  a  moderate  board. 
He  proposes  it  as  a  tentative  measure  applicable  to  Scotland, 
and  fitted  to  gain  experience  to  guide  in  the  establishment  of 
similar  institutions  of  the  pauper  class,  and  in  other  parts  of 
the  Empire.  In  its  preamble  he  states  that — "  Whereas  by  the 
Acts  20  &  21  Victoria,  c.  71,  25  &  26  Victoria,  c.  54,  29  &  30 
Victoria,  c.  51,  and  34  &  35  Victoria,  c.  55,  provision  is  made  for 
the  care  and  treatment  of  lunatics  in  Scotland,  but  no  adequate 
provision  is  made  in  these  Acts,  or  by  the  law  of  Scotland,  for  the 
care  and  proper  treatment  of  persons  who,  although  not  exhibiting 
such  symptoms  as  would  warrant  a  medical  practitioner  to  grant  a 
certificate  for  their  confinement  in  a  lunatic  asylum,  are  yet  labour- 
ing under  a  special  form  of  mental  disorder,  the  chief  distinguish- 
ing features  of  which  are — excessive  and  secret  indulgence  in 
intoxicants,  the  craving  for  which  is  more  or  less  persistent,  or 
occurring  in  fits,  with  remissions  at  intervals  of  time,  and  a  marked 
change  in  the  mental  powers  and  moral  character.  And  whereas 
such  persons,  by  their  habits  and  conduct,  embitter,  disturb,  or 
break  up  domestic  or  social  relations,  and  in  many  cases  bring 
themselves,  or  families,  or  others  into  a  state  of  degradation,  or 
ruin,  or  danger  of  life,  it  is  expedient  and  necessary  for  the  protec- 
tion both  of  them  and  others  that  such  persons  as  above  described 
should  be  cared  for,  by  providing  means  for  placing  them  in  tem- 
porary retirement,  in  a  place  of  residence  other  than  a  lunatic 
asylum,  under  proper  care  and  medical  treatment,  and  under  such 
restraint  as  will  prevent  them  from  having  opportunities  of  con- 
tinuing such  vicious  and  ruinous  indulgences,  whereby  a  permanent 
cure  may  reasonably  be  expected."  In  this  preamble  it  will  be 
observed  that  there  is  no  reference  to  other  kinds  of  indulgence 
than  the  alcoholic — none  to  morphia  or  chloral ;  and  it  may  be  a 
question  whether  this  ought  not  to  be  considered.  The  memo- 
randum prefixed  to  the  Bill  discusses  its  provisions  with  great  care, 
and  explains  many  of  the  proposals.  Eecognising  the  necessity  for 
a  qualified  and  central  authority  to  carry  out  its  provisions,  the 
Bill  ordains  that  the  Board  of  Commissioners  in  Lunacy,  and  the 
District  Lunacy  Boards,  should  be  entrusted  with  this  duty,  and 
that  the  small  assessments  which  may  be  required  should  be  raised 
along  with  those  for  the  purposes  of  the  Lunacy  Acts.  It  proposes 
to  give  the  Lunacy  Board  power,  after  due  inquiry  as  to  the  neces- 
sity for  the  establishment  of  homes  in  each  district  for  the  recep- 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  1053 

tion  of  inebriates,  to  provide  general  accommodation  in  a  district 
home,  or  to  license  the  establishment  of  private  homes  for  care  and 
treatment  under  due  medical  supervision.  The  Commissioners  in 
Lunacy  are  also  authorized  to  frame  rules  both  for  the  conduct  of 
district  and  private  homes,  and  scales  of  charges  for  patients  of 
different  grades  as  respects  their  ability  to  pay  for  board  and  treat- 
ment,— all  this  subject  to  the  consideration  and  approval  of  the 
Secretary  for  Scotland. 

It  proposes  that  patients  should  be  admitted  to  one  of  the 
licensed  homes  upon  his  own  application  to  the  superintendent. 
If  he  should  refuse  to  apply,  the  Bill  gives  power  for  admission  and 
forcible  detention  by  the  following  process : — Any  member  of  the 
patient's  family,  any  other  near  relative  or  friend  taking  interest 
in  him,  or  when  there  is  no  relative  or  friend  to  act,  a  magistrate 
in  the  public  interest,  may  present  an  application  to  the  sheriff  to 
grant  an  order  for  reception  and  detention  in  a  home. 

It  is  not  proposed  that  the  application  should  be  intimated  to 
the  patient,  but  the  applicant  must  make  a  solemn  statutory 
declaration  equivalent  to  an  affidavit,  fully  setting  forth  the  cir- 
cumstances of  the  case.  Two  private  friends  of  the  inebriate,  who 
are  well  acquainted  with  him,  his  family,  and  circumstances,  must 
make  similar  solemn  statutory  declarations;  that  one,  or  if  thought 
proper,  two  medical  men  should  also  certify,  upon  soul  and  con- 
science, as  to  the  patient's  condition.  Upon  such  evidence  the 
sheriff  is  to  proceed  to  consider  whether  he  ought  to  grant  an  order 
for  reception  and  detention.  It  is  believed  that  in  this  way  the 
necessary  powers  are  given,  without  risk  of  interference  with  the 
liberty  of  the  subject. 

With  regard  to  the  period  of  detention,  it  is  proposed,  in  accord- 
ance with  the  recommendation  of  the  Select  Committee  of  the 
House  of  Commons  and  Upper  House,  that  it  should  be  for  twelve 
months  at  least ;  but  power  is  granted  for  earlier  discharge  should 
circumstances  require  it,  or  for  prolonged  detention  if  that  course 
should  be  found  necessary. 

It  is  provided  that  the  patient  may  at  any  time  appeal  to  the 
sheriff  for  recall  of  the  order  and  discharge,  or  to  the  Commis- 
sioners in  Lunacy,  with,  of  course,  the  right  of  appeal  to  the 
Secretary  of  State. 

It  appears  to  me  that  what  has  been  said  makes  it  clear  that  an 
urgent  need  exists  for  legislation,  if  the  proper  legislation  can  be 
devised ;  that  the  existing  legislation,  although  to  a  certain  extent 
of  value,  is  insufficient  to  meet  our  necessities;  and  that  the 
general  scope  of  Mr  Morton's  bill  is  excellent,  and  many  of  the 
details  admirably  devised,  so  as  to  give  us  something  distinctly  in 
advance  of  what  we  have  attained.  The  safeguards  provided  for 
the  liberty  of  the  subject  are  amply  sufficient,  both  as  to  the  pre- 
cautions taken  to  prevent  wrongous  admission,  and  those  to 
diminish   the  risk   of  undue  detention.     Although  it  may  seem 


1054  MEETINGS   OF   SOCIETIES.  [MAY 

somewhat  hard  to  add  to  the  duties  already  discharged  by  the 
Lunacy  Board,  certainly  no  existing  institution  could  compare 
with  it  in  fitness  for  the  work,  and  it  would  be  difficult  to  conceive 
how  a  board  could  be  devised  better  fitted  to  discharge  the  duty, 
even  if  such  a  board  were  to  be  framed  of  set  purpose.  It  may 
be  held  by  some  that  there  would  be  no  need  of  establishing 
district  homes  at  the  expense  of  the  rates,  inasmuch  as  private 
establishments  of  the  kind  would  be  speedily  set  up  if  legislation 
of  a  permanent  kind  warranted  their  formation ;  and  it  is  possible 
that  this  view  is  correct.  But  in  its  main  points  it  appears  to  me 
that  if  such  an  enactment  as  this  Bill  proposes  was  passed  into 
law,  we  might  reasonably  count  upon  a  perceptible  diminution 
of  the  sum  of  human  misery,  the  cure  of  not  a  few  who  have 
become  the  subject  of  this  evil,  and  much  benefit  to  their  relatives 
and  estates. 

Dr  Yellowlees,  Gartnavel  Eoyal  Asylum,  said — I  certainly  would 
not  have  willingly  intruded  so  soon.  I  would  rather  have  listened, 
but  since  you  have  asked  me,  and  since  trains  are  inexorable,  I  will 
say  a  few  words  now.  I  think  Prof.  Stewart  has  done  a  great  deal 
in  clearing  the  ground.  Nothing  more  need  be  said  about  the 
characteristics  of  the  habitual  drunkard.  He  has  put  them  so 
admirably  before  us,  and  so  perfectly  are  they  sketched  in  the 
preamble  of  the  Bill,  and  also  in  the  Eeport  of  the  Dalrymple 
Commission,  I  need  say  no  more  of  them.  "We  all  know  these 
cases  quite  well,  and  we  know  from  our  own  observation  harrow- 
ing details  of  the  danger,  the  misery,  and  the  ruin  that  such  a 
patient  entails  upon  himself  and  his  family.  I  need  say  nothing 
more  as  to  that.  I  take  it  that  the  chief  object  of  our  meeting  is 
not  to  discuss  this  aspect  of  the  question,  but  to  let  the  public 
know  how  strong  and  how  unanimous  our  feeling  is  that  such 
cases  demand  far  greater  care  than  we  can  at  present  give  them. 
At  least  we  desire  to  inform  such  of  the  public  as  do  not  already 
know.  There  are  no  sceptics  among  those  who  have  had  in  their 
own  family  or  acquaintance  a  habitual  drunkard.  That  is  the 
saddest  argument  and  the  most  convincing  one.  We  are  all 
agreed  as  to  the  misery  and  distress  thus  caused,  and  as  to  the 
necessity  for  something  being  done,  and  we  are  all  agreed  as  to 
the  helplessness  of  such  cases  without  some  one  helping  them. 
The  misery  of  it  is  that  most  of  these  people  will  not  have  the 
help.  We  are  all  agreed,  too,  as  to  the  frequent  hopelessness  of 
cure.  He  was  a  very  sanguine  man  who  found  two-thirds  of  the 
cases  in  one  of  the  retreats  recover !  I  am  quite  sure  that  those 
of  us  who  have  the  widest  experience  of  such  cases  have  the 
darkest  tales  of  failure  to  record.  I  think  that  the  only  hope  is 
in  enforced  abstinence,  and  the  abstinence  is  useless  unless  con- 
tinued for  a  long  time — a  year  at  least.  We  are  all  agreed,  too, 
that  our  present  mode  of  dealing  with  such  cases  is  a  miserable 


1889.]  MKDICO-CHIRUUGICAL   SOCIETY   OF   EDINBURGH,  1055 

failure.     If  poor  people,  they  get  into  jail.     That  is  not  to   be 

regretted.     It  is  the  best  thing  that  could  happen  to  them,  as  the 

law  now  stands.     Keferring  to  the  case  mentioned  by  Dr  Stewart, 

I  do  not  think  it  is  to  be  regretted  that  that  man  was  five  years  in 

jail.     It  was  best  for  the  man  and  best  for  the  public,  and  the 

public  have  a  right  to  be  considered ;  if  they  could  have  kept  him 

longer,  it  would  have  been  far  better.     The  futility  of  the  jail 

treatment  for  short  periods  is  perfectly  certain,  but  there  are  some 

"habituals"  so  bad  and  so  hopeless  that  the  only  course  is  to 

put  them   beyond   doing  mischief  to  their  neighbours.      If   the 

patient  is  not  poor,  you  may  try  to  get  him  into  an  asylum  as  a 

voluntary   patient — that   is,   provided   you    can  get    an    asylum 

superintendent  good  natured  enough  to  admit  him.     I  habitually 

and  deliberately  refuse  such  patients.     I  refuse  them  for  their 

own  sakes,  because  they  presently  get  so  absolutely  certain  that 

they  are  well  that  you  cannot  persuade  them  to  remain  long  enough 

to  get  any  real  good,  and  I  object  to  them  for  the  sake  of  the 

other  patients  as  well.     I  say  you  have  no  right  to  impose  the 

company   of    such  liars    and   mischiefmakers    upon    respectable 

lunatics.      The  next  thing  you  probably  do,  if  you  cannot  get 

them  into  an  asylum,  is  practically  to  banish  them.     You  send 

them  to  a  remote  part  of  the  country,  to  Skye  or  Orkney,  if  you 

can  get  people  to  keep  them — where  you  deprive  them  of  money, 

and  where  they  associate  with  people  as  bad  as  themselves.     I  have 

often  thought  that  the  moral  tone  of  these  inebriate  refuges  must 

be  of  the  lowest.     And  still  another  most  miserable  recourse  is 

to  send  them  abroad,  to  let  them  drink  themselves  to  death  where 

they  wont  disgrace  their  friends.     The   present  modes  are  thus 

miserable  failures.     Legislation  hitherto  has  been  useless,  and  the 

Habitual   Drunkards   Act  a   complete   failure.      This   was   fully 

expected  at  the  time.     Dr  Cameron,  who  fought   hard   for  the 

Act,  told  me  that  it  was  hopeless  to  try  to  carry  the  compulsory 

clause.     The  choice  was  between  this  Act  or  nothing,  and  he  took 

this  with  the  hope  that  something  better  might  be  got  next  time. 

We  are  all  satisfied  as  to  the  need  of  something  better,  and  this 

seems  a  good  time  to  legislate,  as  the  Habitual  Drunkards  Act 

expires  next  year  (I  am  just  told  it  has  been  renewed  again) ; 

but  I  doubt  very  much  if  you  will  get  anything  so  sensible  and  so 

needful  carried  through,  as  the  time  of  Parliament  seems  to  be 

taken  up  with  discussing  such  very  important  questions  as  what 

kind  of  breeches  an  Irish  patriot  shall  wear.     Mr  Morton's  Bill  is 

only  too  good.     It  is  too  good,  because  it  is  a  great  deal  more  than 

is  attainable.     I  wish  it  could  be  got,  but  I  have  no  hope  whatever 

that  many  of  its  provisions  will  be  carried  out.     I  have  no  hope 

that  the  Commissioners  in   Lunacy  will   undertake  the  care  of 

habitual  drunkards  in  addition  to  their   present  duties,  though 

none  could  care  for  them  so  well ;  and  I  have  no  hope  whatever 

that  the  assessment   clauses   which   the   Bill  contains  could   be 


1056  MEETINGS   OF   SOCIETIES.  [MAY 

carried.  If  they  are  dropped,  then  the  only  practical  difference 
between  Mr  Morton's  Bill  and  the  Habitual  Drunkards  Act  is  the 
compulsory  clause.  At  present,  without  that  compulsory  clause 
the  Habitual  Drunkards  Act  is  useless — sadly  useless. 

(To  be  continued.) 


OBSTETRICAL  SOCIETY  OF  EDINBURGH. 

SESSION  L. — MEETING  IV. 
Wednesday,  13th  February  1889. — Dr  Underbill,  President,  in  the  Chair. 

I.  Dr  O.  S.  Macgregor,  showed  for  Dr  Halliday  Groom — (1.) 
A  large  unilocular  ovarian  tumour.  (2.)  A  dermoid  ovarian 
TUMOUR.  (3.)  Tubes  and  ovaries  removed  from  patient,  who  has 
suffered  for  3  years  from  salpingo-ovaritis  of  gonorrhoeal  origin. 

II.  Dr  Foulis  showed  his  mercuric  pellets. 

III.  Dr  Felkin  read  his  paper  on  "fcetal  malaria,"  which 
will  appear  in  a  future  number  of  this  Journal. 

Professor  Simpson  said  that  he  believed  that  the  cases  brought 
before  them  in  Dr  Felkin's  paper  opened  up  a  perfectly  new  view 
of  the  mode  of  development  of  malaria  in  the  fcBtus  in  utero,  and 
would  like  to  know  if  Dr  Felkin  had  himself  found  in  obstetric 
literature  any  hint  of  the  occurrence  of  the  mischief  in  infants 
whose  mothers  were  free  of  the  disease.  As  the  cases  were  being 
read,  the  analogy  which  Dr  Felkin  had  pointed  out  with  the  pro- 
duction of  syphilis  had  occurred  to  him  (Prof.  Simpson)  as  it  had 
doubtless  to  the  other  fellows,  and  he  thought  that  Dr  Felkin  was 
entirely  justified  in  the  conclusions  he  had  drawn  from  his  valu- 
able record  of  these  striking  and  instructive  cases. 

The  President  was  greatly  interested  in  Dr  Felkin's  cases  and 
the  deductions  he  had  drawn  from  them.  The  second  case  seemed 
to  prove,  without  any  possibility  of  doubt,  that  the  malarial  poison, 
whatever  its  nature  may  be,  can  be  transmitted  direct  from  the 
father  to  the  foetus  without  infecting  the  mother.  The  first  case 
seemed  less  certainly  confirming  this  view,  because  malaria  may 
sometimes  be  latent.  The  only  case  of  ague  he  had  seen  in  con- 
nexion with  pregnancy  occurred  in  a  lady  who  had  been  born  in 
India,  and  had  been  there  until  she  was  seven  years  old.  She 
then  came  home,  and  married  at  the  age  of  23.  At  25  she  had 
her  first  child,  having  never  suffered  either  in  infancy,  so  far  as 
she  knew,  nor  since  she  left  India  from  any  malarial  disease.  On 
the  day  following  delivery  she  had  a  severe  attack  of  ague,  and 
these  attacks  occurred  every  second  day  for  about  a  fortnight,  and 
then  passed  off.  This  woman  must  have  had  the  disease  latent  in 
her  system  from  the  time  she  left  India. 

Dr  Felkin  said,  in  reply  to  Professor  Simpson,  that  although  he 
could  not  profess  to  be  acquainted  with  all  the  literature  on  the 


1889.]  OBSTETRICAL   SOCIETY   OF   EDINBURGH.  1057 

subject  of  malaria,  he  had  studied  it  extensively,  and  to  the  best  of 
his  knowledge  there  was  no  case  on  record  of  a  similar  nature. 
He  had  only  to-day  seen  in  a  paper  by  Dr  L.  Thomas  (p.  308, 
Archiv  der  Heilkunde,  1866),  a  vague  hint  in  relation  to  the  point 
in  question,  Dr  Thomas  says,  "  I  know  not  if  cases  are  on  record 
in  which  it  can  be  proved  that  newly  born  infants  are  sufifering 
from  malarial  cachexia  where  the  mother  had  not  suffered  from 
malaria."  But  this  is  hardly  to  the  point,  as  he  does  not  refer  to 
children  suffering  from  malaria  in  utero.  With  reference  to  Dr 
Hart's  remarks,  Dr  Felkin  said  that  a  very  great  number  of  children 
born  in  the  tropics  were  born  suffering  from  malarial  cachexia, 
and  many,  too,  from  ague-cake.  In  fact,  ague-cake  in  many  cases 
delayed  delivery  and  often  obliged  the  use  of  forceps.  Baxa  in  Pola 
said  that  90  per  cent,  of  children  suckled  by  mothers  or  nurses 
suffering  from  malaria  had  ague,  and  that  30  per  cent,  died  in  the 
first  year  of  life.  Luck  {Rec.  de  Mem.  de  MM  de  Chir.  1864,  Nov.) 
relates  a  case  in  which  a  nurse  who  had  suffered  from  malaria  in 
Algiers  returned  to  France,  and  though  apparently  free  from  malaria 
at  the  time,  suckled  a  child  whose  parents  were  perfectly  free  from 
it,  and  after  three  months  it  suffered  from  tertian  ague.  And  he 
warns  against  the  employment  of  wet  nurses  from  malarious  dis- 
tricts. Another  very  interesting  case  could  be  referred  to,  but  it  is 
too  long;  it  is  given  by  Sous  {Journal  de  Bordeaux,  Mai,  1857). 
It  is  a  rule  in  tropical  countries  to  reject  a  wet  nurse  (if  possible) 
suffering  from  an  enlarged  spleen,  and  it  is  also  usual  to  examine 
her  child  to  see  that  it  is  free  from  malarial  cachexia  or  ague-cake. 
In  India,  too,  it  is  necessary  to  see  that  the  child  is  not  a  borrowed 
one,  as  wet  nurses  in  that  country  are  apt  to  be  very  cunning.  There 
are  also  cases  on  record  in  which  persons  from  a  malarious  district 
suffering  from  malaria  have  slept  with  healthy  persons  and  have 
given  them  the  disease.  This  last  fact,  however,  is  very  doubtful, 
and  the  experience  in  all  great  epidemics  seems  to  totally  disprove 
the  observation.  It  may  be  well  to  mention  one  or  two  other  facts 
with  regard  to  malaria.  Hirsch  does  not  believe  in  the  con- 
tagiousness of  malaria,  but  he  admits  that  it  may  be  conveyed 
from  place  to  place,  basing  this  conclusion  on  Salisbury's  experi- 
ment of  taking  earth  from  a  malarious  spot  to  one  which  was 
free  from  the  disease  and  placing  it  on  the  window-sill  of  a 
room  of  a  second  floor  in  which  two  persons  slept.  The  window 
was  kept  open  at  night.  Six  days  after  both  the  persons  who  slept 
in  this  room  complained  of  being  unwell,  and  on  the  12th  day  the 
one,  and  on  the  14th  the  other,  was  attacked  by  ague  of  a  tertian 
character.  And  Sawyer  records  a  case  in  which  it  is  almost  certain 
that  malaria  must  either  be  contagious  or  that  it  can  be  conveyed 
in  clothes  or  other  effects.  Dr  L.  Thomas  {Archiv  der  Heilkunde, 
1866)  is  strongly  of  the  opinion  both  that  malaria  is  contagious  and 
that  it  may  be  given  from  a  nurse  to  a  healthy  infant,  or  that  an 
unhealthy  infant  can  infect  a  nurse.     In  reply  to  the  president, 

EDINBURGH   MED.   JOURN.,   VOL.   XXXIV. — NO.   XI.  6   S 


1058  MEETINGS   OF   SOCIETIES.  [MAY 

Dr  Felkin  said  that  he  still  thought  that  his  first  case  was  due  to 
malaria  transmitted  by  the  father.  The  lady  came  from  a  non- 
malarious  district,  and  the  closest  inquiries  had  failed  to  bring  out 
any  symptom  of  even  masked  malaria,  but  of  course  he  could  not 
be  answerable  for  her  parents  or  grandparents,  although  he  ob- 
tained no  history  of  malaria  having  affected  the  parents.  The  case 
to  which  the  president  referred  was  one  of  great  interest,  but  it  was 
not  an  uncommon  thing  to  find  that  persons  who  had  lived  for  many 
years  in  a  malarious  district  were  first  attacked  by  frank  ague  after 
their  return  home.  In  these  cases  the  poison  had  evidently  lain 
dormant,  or  it  had  only  previously  manifested  itself  as  masked 
malaria,  the  symptoms  of  which  were  often  unrecognised  by  the 
patients.  Any  acute  disease,  however,  or  parturition,  was  quite 
capable  of  inducing  in  them  unmistakable  ague.  Dr  Felkin 
begged  to  thank  the  Society  for  the  way  in  which  they  had  received 
his  paper. 

IV.  Dr  Barbour  read  his  paper  "  ON  THE  light  which  sectional 

ANATOMY  WILL  THROW  ON  THE   MECHANISM  OF  LABOUR,"  which  will 

appear  in  a  future  number  of  this  Journal. 

Dr  Berry  Hart  thought  Dr  Freeland  Barbour's  paper  very 
valuable.  Of  course  one  would  require  to  read  and  study  it  carefully 
before  giving  any  definite  opinion,  but  it  was  evident  that  Dr 
Barbour's  criticisms  were  justified,  especially  as  to  the  movement 
of  flexion.  Dr  Hart  had  always  taught  that  it  only  meant  that 
one  more  easily  felt  the  occiput  on  examination. 

Professor  Simpson  agreed  with  Dr  Hart  as  to  the  value  of  the 
observation  contained  in  Dr  Barbour's  communication,  and  thought 
the  point  was  important  which  had  been  developed  as  to  the 
attitude  of  the  foetus.  He  (Prof.  Simpson)  was  not  prepared  to 
accept  the  observation  as  to  the  apparent  absence  of  flexion  as  a 
correct  explanation  of  the  relations  of  the  head  to  the  pelvic  canal 
during  its  descent.  In  the  so-called  head-flexion  of  labour  the 
essential  phenomenon  was  a  descent  of  the  occiput  in  advance  of 
the  sinciput ;  and  whilst  this  might  at  first  be  due  to  simple  nuta- 
tion, it  usually  resulted  from  a  rotation  of  the  whole  child,  and  not 
merely  of  the  head,  on  its  transverse  axis ;  and  in  the  second  of 
Braune's  plates  it  appeared  to  him  that  the  occiput  was  lower  than 
the  sinciput,  although  the  whole  child  under  the  lateral  compression 
of  the  uterus  might,  on  the  whole,  be  somewhat  extended. 

Dr  Barbour  thanked  the  fellows  for  the  reception  they  had  given 
to  his  paper.  He  would  emphasize  what  he  had  said  as  to  the 
caution  with  which  the  results  of  sectional  anatomy  must  be  taken  ; 
we  had  only  a  few  sections  as  yet,  too  few  to  generalize  from. 
Further,  we  could  not  tell  what  the  post-mortem  changes  were;  for 
example,  the  settling  down  of  the  uterus  due  to  post-mortem 
relaxation  of  the  tissues  would  make  the  lower  segment  appear 
lower  in   the  pelvis   than  during  life.     The   fact  remained   that 


1889.]  OnSTETRICAL   SOCIETY   OF   EDINBUKGH.  10o9 

Braune's  and  Chian's  sections  for  the  second  stage  show  the  head 
of  the  child  relative  to  its  body  to  be  if  anything  less  flexed  than 
it  appeared  in  the  frozen  section  made  during  pregnancy.  He 
quite  agreed  with  what  Professor  Simpson  said,  that  the  important 
point  was  the  relation  of  the  head  to  the  canal. 

V.  Dr  Berry  Hart  read  a  "  note  ON  some  anomalous  separa- 
tions OF  THE  placenta  PRIOR  TO  THE  BIRTH  OF  THE  CHILD,"  wMch 
appeared  at  page  900  of  this  Journal. 

Dr  Barlour  was  sorry  that  Dr  Helme  was  not  here  to  reply  to 
Dr  Hart's  criticism.  He  said  distinctly  in  his  paper  that  the 
second  placenta  was  not  adherent;  he  compared  the  feeling  in  pass- 
ing the  hand  between  the  placenta  and  its  wall  to  passing  the 
hand  through  butter,  a  term  hardly  applicable  to  an  adherent 
placenta.  As  to  Dr  Hart's  exposition  of  his  theory,  he  spoke  as  if  it 
alone  turned  on  a  disproportion  of  placenta  and  its  site ;  while  the  old 
view  turned  equally  on  this,  the  difference  being  that  the  latter 
implied  that  the  placenta  was  unable  to  follow  the  diminution  of  its 
site,  while  Dr  Hart's  implied  that  it  could  not  follow  its  expansion. 
Dr  Barbour  believed  that  disproportion  might  operate  after  the  area 
of  4  in.  X  4  in.  had  been  reached ;  only  with  that  amount  of 
diminution  of  area  the  uterus  came  to  grasp  the  placenta  all  round, 
and  we  must  take  into  account  the  action  of  the  uterine  wall  as  a 
whole  on  the  placental  mass. 

Dr  Foulis  reported  to  the  Society  a  case  of  adherent  placenta, 
which  after  an  hour's  waiting  he  caused  to  be  separated  by  giving 
the  patient  subcutaneously  twelve  minims  of  Professor  Simpson's 
solution  of  ergotin.  This  brought  on  very  powerful  contractions 
of  the  uterus,  and  during  one  of  these  contractions  the  placenta 
was  both  separated  and  expelled.  For  an  hour  Dr  Foulis  kept  his 
hand  on  the  uterus  with  the  adherent  placenta,  and  time  after  time 
he  felt  the  uterus  relax  and  then  contract,  but  still  there  was  no 
separation  of  the  placenta ;  and  although  the  contractions  were 
pretty  strong,  not  one  drop  of  blood  escaped  during  the  whole  time, 
showing  that  the  placenta  was  still  adherent.  This  was  not  a  case 
of  retained  placenta.  It  was  firmly  adherent  to  the  uterine  wall 
everywhere,  and  the  relaxations  and  contractions  of  the  uterus 
quite  failed  to  separate  and  expel  it.  It  was  only  after  the  ergotin 
solution  was  given  subcutaneously  that  the  uterine  contractions 
were  sufficiently  strong  to  separate  the  placenta,  and  when  it  was 
expelled  there  was  a  great  gush  of  perfectly  fluid  crimson  blood, 
and  not  a  particle  of  clot.  Dr  Foulis  paid  special  attention  to 
this  point,  as  the  absence  of  any  clot  and  the  escape  of  only  liquid 
crimson  blood  immediately  following  the  escape  of  the  placenta 
showed  that  the  placenta  had  just  been  separated  by  the  powerful 
uterine  contraction.  In  this  case  uterine  relaxations  entirely 
failed  to  separate  the  adherent  placenta.  It  required  a  very 
powerful  uterine  contraction  to  separate  the  placenta.     Dr  Foulis 


1060  ,  MEETINGS   OF   SOCIETIES.  [MAT 

then  called  the  attention  of  the  Society  to  the  following  extract  from 
Dr  Hart's  recently  published  paper  on  separation  of  the  placenta : 
"  If  the  uterus  be  palpated  during  the  third  stage,  it  will  be  noted 
to  harden  and  diminish  in  bulk  markedly,  and  then  to  increase  in 
bulk  and  become  softer.  During  the  hardening  the  internal  uterine 
surface  diminishes  greatly,  the  contraction  ring  'barely  admitting  the 
finger,  and  the  uterine  wall  thickens  :  during  relaxation  the  internal 
uterine  area  increases  so  that  the  hand  passed  in  can  he  even  moved 
about  freely^  and  the  contraction  ring  expands  so  as  to  allow  the  hand 
to  pass.  The  condition  of  the  uterine  wall  is  not  known  exactly, 
but  I  believe  it  is  thinner.  Unfortunately  we  do  not  know  how 
the  relaxing  muscle  increases  the  internal  uterine  surface  in  area, 
but  as  a  matter  of  fact  it  does,  and  this  diastole  is  probably 
active."  A  little  further  on  in  this  paper  Dr  Hart  goes  on  to  say  : 
"  When  the  uterus  contracts  to  the  amount  it  does  after  the  child 
is  born,  the  placenta  fills  the  uterine  cavity,  etc."  So  that  Dr  Hart 
wishes  us  to  believe,  that  though  the  placenta  "  fills  the  uterine 
cavity  after  the  child  is  born,"  yet  during  relaxation  the  internal 
uterine  area  increases  so  that  the  hand  passed  in  can  be  moved 
about  freely,  and  the  contraction  ring  expands  so  as  to  allow  the 
hand  to  pass."  Dr  Foulis  ventured  to  say  that  Dr  Hart  was  quite 
wrong  in  his  physics.  Did  Dr  Hart  mean  to  tell  us  that  when  the 
vaginal  surfaces  were  in  contact  and  the  uterine  wall  closely 
grasped  the  enclosed  placenta,  that  the  uterus  could  so  relax  as  to 
produce  a  cavity  in  which  the  hand  could  be  freely  moved  about. 
This  was  against  the  laws  of  Nature,  as  Nature  abhorred  a  vacuum. 
Dr  Hart  seemed  to  forget  that  when  he  inserted  his  hand  into  the 
uterus  things  were  altogether  changed.  If  it  was  true  that  the 
uterus  closely  grasped  the  placenta  and  the  vaginal  walls  were  in 
contact  after  the  child  was  born,  then,  Dr  Foulis  maintained,  the 
uterus  could  not  relax  so  as  to  produce  the  cavity  into  which  Dr 
Hart's  hand  could  go.  Dr  Foulis  had  frequently  shown  the 
Society  that  this  relaxation  of  the  uterine  wall  was  nothing  more 
or  less  than  a  swelling  up  of  the  wall  of  the  uterus  caused  by 
distension  of  all  the  vascular  channels  in  its  substance,  brought 
about  by  the  pumping  action  of  the  left  ventricle  of  the  heart 
after  the  uterine  contraction  was  over,  and  that  as  long  as  neither 
blood  nor  air  escaped  into  the  uterine  cavity  the  uterine  wall  did 
not  leave  go  of  its  tight  grasp  of  the  placenta,  let  it  swell  up  ever 
so  much,  but  this  swelling  up  was  limited  as  long  as  blood  did  not 
escape  into  the  uterine  cavity.  Dr  Foulis  begged  Dr  Hart  to 
reconsider  his  theory  of  separation  of  the  placenta. 

Dr  Berry  Hart  thanked  the  Fellows  for  their  reception  of  his 
paper.  Dr  Freeland  Barbour  now  granted  that  a  disproportion 
between  placental  site  and  area  was  necessary  for  separation,  and 
Dr  Hart  held  that  this  disproportion  was  impossible  during  the 
uterine  retraction  which  caused  diminution  of  area.  Dr  Foulis 
had  misunderstood  his  paper,  as  Dr  Hart  held  that  the  necessary  dis- 


1889.]  OBSTETRICAL  SOCIETY   OF   EDINBUKGH.  1061 

proportion  for  separation  was  microscopic,  and  that  what  was  termed 
"  the  relaxation  following  a  pain  "  was  physiological  and  unaccom- 
panied at  first  by  bleeding.  Dr  Foulis  denied  that  the  internal 
uterine  area  increased  at  all  during  the  third  stage,  but  that  it  did 
so  was  a  fact  known  to  most  observers.  Dr  Foulis  denied  that 
the  blood  was  aspirated  from  the  foetal  portion  of  the  placenta,  but 
here  again  most  observers  were  against  him.  The  case  Dr  Foulis 
related  was  evidently  one  where  the  placenta  lay  blocking  the 
lower  uterine  segment  or  vagina,  damming  the  effused  blood  back. 
The  placenta  was  separated  and  driven  down,  inasmuch  as  Dr 
Foulis  described  the  uterus  as  flattened.  Dr  Foulis's  theory  that 
the  internal  uterine  area  never  increased  after  the  pain  died  off, 
and  that  the  increase  of  uterine  bulk  was  due  to  blood  in  the 
uterine  walls,  was  untenable.  As  to  the  treatment  based  on  Dr 
Hart's  view,  it  was,  so  far  as  Dr  Hart  had  tried  it,  perfectly  satis- 
factory, and  had  given  better  results  than  Crdd^'s  method,  which 
Dr  Hart  held  to  be  wrong  and  dangerous  if  used  for  the  separation 
of  the  placenta. 


PERISCOPE. 

MONTHLY  REPORT  ON  THE  PROGRESS  OF  THERAPEUTICS. 

By  William  Craio,  M.D.,  F.R.S.E.,  Lecturer  on  Materia  Medica,  Edinburgh 
School  of  Medicine,  etc.,  etc. 

The  Treatment  of  Night-Sweats  by  the  External  Use  of 
Chloral. — According  to  the  Gazette  MMical,  Dr  Nicolai  has 
obtained  good  results  in  the  night-sweats  of  the  phthisical  by  the 
employment  of  an  embrocation  of  hydrate  of  chloral,  two  drachms 
dissolved  in  a  tumblerful  of  brandy  and  water.  Every  night  about 
bed-time  the  patient  is  rubbed  all  over  with  a  sponge  dipped  in 
this  solution.  Sometimes  three  or  four  rubbings  suffice  to  effect 
the  complete  disappearance  of  night-sweats,  which  have  previously 
lasted  for  weeks  {Boston  Medical  and  Surgical  Journal,  January 
10,  l^^^).— Therapeutic  Gazette,  February  1889. 

Butyl-chloral  in  Trigeminal  Neuralgia. — There  are  but 
few  remedies  which  exert  their  action  on  a  special  division  of  the 
nervous  system  alone.  According  to  Dr  O.  Leibreich,  butyl-chloral 
illustrates  an  exception  to  the  general  rule,  since  he  claims  that, 
when  administered  internally  in  doses  of  from  15  to  45  grains,  it 
produces  anaesthesia  in  the  region  supplied  by  the  trigeminal  nerve. 
He  therefore  has  employed  it,  and  he  claims  with  success,  in 
neuralgic  affections  of  the  trigeminal  nerve,  it  serving  to  reduce 
facial  pain  dependent  either  upon  rheumatism,  traumatic  pain  from 
inflammation  of  the  pulp  of  the  teeth,  or  periostitis,  while  it  may 
likewise  serve  to  reduce  the  pain  experienced  in  filling  the  teeth. 


1062  PEKiscorE.  [may 

The  taste  of  butyl-chloral  is  extremely  disagreeable,  and  it  is  highly 
insoluble,  and  needs  some  special  form  of  prescription.  He  recom- 
mends it  to  be  combined  with  alcohol  and  glycerin — 1  part  of 
butyl-chloral  to  2  of  alcohol  and  4  of  glycerin  in  240  parts  of  water 
{Internationale  Klinische  JRundschaUj  December  16,  1888). — 
Therapeutic  Gazette,  February  1889. 

A  New  Anthelmintic. — Dr  Parisi  accidentally  discovered  that 
the  cocoa-nut  possesses  anthelmintic  properties.  Two  hours  after 
eating  tlie  endocarpium  of  the  nut  and  drinking  the  juice  he  felt 
slight  nausea,  gastric  disturbances,  and  slight  diarrhoea.  On  the 
following  morning  he  passed  a  large  taenia,  with  the  head  attached. 
Thinking  that  perhaps  the  cocoa-nut  had  led  to  this  result,  he  made 
inquiries  as  to  whether  similar  success  had  ever  been  attributed  to 
the  use  of  the  cocoa-nut,  but  without  obtaining  any  satisfactory 
replies.  He  then  repeated  the  experiment  on  his  patients  in  Athens  ; 
in  six  cases  he  noted  success  in  producing  the  evacuation  of  the 
taeniae.  Should  Dr  Parisi's  results  be  confirmed,  the  cocoa-nut  is  to 
be  preferred  as  an  anthelmintic  from  the  fact  that  it  needs  no 
previous  preparation,  and  on  account  of  its  freedom  from  dis- 
agreeable taste,  etc.  (Schmidt's  Jahrbucher,  December  15,  1888). — 
Therapeutic  Gazette,  February  1889. 

Phenacetine. — This  substance  as  regards  its  chemical  composi- 
tion is  analogous  to  antifebrin.  It  is  given  in  doses  of  10  to  15 
grains.  In  the  Therapeutic  Gazette  for  March  is  a  leading  article 
giving  the  experiences  of  several  distinguished  experimenters  who 
liave  tried  it — all  proving  its  value  as  an  antipyretic,  and  also  as 
an  excellent  remedy  in  neuralgia,  headaches,  etc. 

In  the  British  Medical  Journal  for  30th  March,  Dr  T.  G.  Parrott 
states  that  he  has  treated  successfully  two  obstinate  and  severe 
cases  of  sciatica  with  antipyrin,  as  recommended  by  Dr  Covarriibias 
of  Limache.  He  gave  10  grains  every  three  hours.  He  concludes, 
"  In  the  first  case,  after  taking  the  antipyrin,  the  patient  had  a  good 
night  after  some  weeks  of  sleeplessness ;  in  the  second,  relief  was 
obtained  in  twenty-four  hours." 

Contraindications  for  the  Use  op  Antipyrin  during  the 
Menstrual  Period. — Cases  of  toxic  accidents  from  the  use  of 
antipyrin  have  been  frequently  reported,  but  the  conditions  under 
which  these  results  are  produced  have  not  been  sufficiently  studied. 
Without  doubt  in  some  cases  the  poisonous  effect  is  to  be  attributed 
to  the  poor  quality  of  the  drug,  but  the  condition  of  the  patient  also 
deserves  consideration.  In  the  Bevue  Generale  de  Clinique  et  de 
Therapeutique  for  January  24th,  1889,  Dr  W.  Huchard  states  that  a 
year  ago  he  administered  15  grains  of  antipyrin  to  a  woman  suffer- 
ing from  violent  dysmenorrhcea.  As  the  result  of  the  administration 
of  this  drug,  the  menstrual  flow  was  suddenly  an-ested.  The  patient 
was  seized  with  violent  chill,  chattering  of  the  teeth,  face  became 


1889.]  MONTHLY   REPORT   ON   THERAPEUTICS.  1063 

cyanosed,  and  there  were  frequent  attacks  of  syncope ;  the  pulse  was 
small  and  weak,  and  the  patient  complained  of  great  headache. 
The  condition  was  such  as  to  cause  great  anxiety  for  nearly  an 
hour,  when  the  effects  gradually  passed  off.  Dr  Huchard  thinks 
that  he  has  in  two  other  cases  observed  similar  symptoms,  although 
less  marked,  and  he  now  regards  the  presence  of  the  catamenial 
flow  as  a  positive  contraindication  to  the  use  of  antipyrin. — Thei'a- 
peutic  Gazette,  March  1889. 

A  New  Remedy  for  Cholera. — Loewenthal  (Acad,  des  Sciences, 
Session  December  1888)  has  concluded  a  course  of  experiments, 
undertaken  to  find  an  antidote  to  the  virus  of  cholera.  This  toxic 
principle  is  now,  according  to  the  newest  pathology,  regarded  as 
the  product  of  Koch's  cholera  bacillus — a  ptomaine,  in  fact,  which 
is  destroyed  by  cultivation  in  artificial  nutrient  media.  Loewen- 
thal has  found  that  a  pure  culture  of  these  cholera  bacilli  in  pep- 
tonized, broth,  previously  sterilized,  is  absolutely  inoffensive  to 
animals — as  white  mice — naturally  susceptible  to  the  cholera  poison, 
the  bacilli  ceasing  to  produce  the  noxious  ptomaine.  The  first  aim 
of  Loewenthal's  experiments  was  to  render  to  tiie  cholera  bacillus, 
by  a  process  of  the  laboratory,  the  toxic  property  which  it  possesses 
when  fresh,  but  which  is  lost  on  cultivation.  After  many  fruitless 
essays,  he  believes  that  he  has  succeeded  with  a  paste  which  con- 
tains pancreatin,  and  the  composition  of  which  is  as  follows :  fresh 
pork  (muscle),  hashed,  500  grammes;  pancreas  of  hog,  hashed,  200 
grammes ;  bean  flour,  100  grammes  ;  peptone,  15  grammes ;  grape 
sugar,  10  grammes;  common  salt,  5  grammes.  These  substances, 
mixed  with  water  or  milk,  give  a  soft  paste,  almost  liquid,  which 
is  rendered  alkaline  by  a  little  potash,  and  then  sterilized  by  hot 
steam.  The  cholera  bacilli,  which  by  culture  have  lost  their  patho- 
genic properties,  are  allowed  to  breed  in  this  artificial  paste.  They 
immediately  secrete  their  virulent  ptomaine,  which,  when  inoculated 
in  mice,  either  kills  these  animals  or  makes  them  intensely  sick. 
By  varying  the  elements  of  his  culture  mixture,  Loewenthal  finally 
satisfied  himself  that  it  is  the  pancreatic  juice  which,  in  presence  oi 
albuminoid  and  peptonized  substances,  determines  the  pathogenic 
or  poison-secreting  action  of  the  bacillus.  All  the  other  culture 
media  (peptone-gelatine,  agar-agar,  bouillon)  assure  the  develop- 
ment of  the  bacillus,  but  no  toxic  matter  is  produced.  This  peculiar 
action  of  the  pancreatic  juice  being  understood,  we  have,  says 
Loewenthal,  an  explanation  of  the  phenomena  of  cholera  in  man. 
The  bacilli,  after  being  ingested,  escape  the  stomach,  and  entering 
the  intestine,  produce  there,  with  the  help  of  the  pancreatic  juice, 
the  same  toxic  matter  which  is  produced  in  the  pancreatic  paste, 
the  latter  being  a  coarse  imitation  of  the  contents  of  the  duodenum ; 
this  toxic  matter  is  absorbed,  and  the  restoration  or  death  of  the 
patient  depends  on  the  quantity  of  poison  absorbed  and  the  resist- 
ance of  the  organism.  This  experimental  fact  is  in  harmony  with 
the  anatomo-pathological  fact,  that  the  bacilli  of  cholera  remain 


1064  PERISCOPE.  [may 

always  confined  to  the  intestine,  as  well  as  with  the  "  fulminant 
cases,"  and  the  experiments  of  Nicoti  and  Reitsch,  and  those  of 
Koch  on  animals.  This  point  being  once  determined,  Loewenthal 
asked  himself  if  there  might  not  be  some  substance  inoffensive  to 
man  whicli,  introduced  medicinally,  would  prevent  the  development 
of  the  cholera  poison  in  the  intestines.  To  determine  this  he  first 
experimented  with  his  pancreatic  paste,  trying  various  antiseptic 
agents  which  he  thought  might  prevent  the  active  functional  opera- 
tions of  the  bacilli  and  the  genesis  of  the  toxic  ptomaine.  Any 
agent,  he  reasoned,  which  can  accomplish  this  out  of  the  lady  might 
be  relied  upon  to  do  the  same  within  the  body,  and  thus  become  a 
specific  (preventive  and  curative)  remedy  for  cholera.  This  remedy 
Dr  Loewenthal  announces  that  he  has  found  in  salol,  salicylate  of 
phenol,  discovered  in  1886  by  Neucki  of  Berne.  This  powerful 
antiseptic  is  decomposed  in  the  organism  by  the  pancreatic  juice, 
the  same  agent  which  renders  toxic  the  cultures  of  th€  cholera 
bacillus  in  the  pancreatic  paste.  A  multitude  of  experiments  have 
assured  him  that  salol  in  presence  of  fresh  pancreatic  juice  is 
invariably  fatal  to  the  cholera  bacilli  in  his  laboratory  culture- 
tubes  ;  and  he  has  determined  the  quantity  which  is  sure  to  effectu- 
ally sterilize  his  cultures,  namely,  2  grammes  of  salol  to  every  10 
grammes  of  the  paste.  A  smaller  dose,  however  (as  10  centi- 
grammes), renders  the  bacilli  inactive.  It  is  known  that  salol  can 
be  taken  in  pretty  large  doses  (as  much  as  10  to  15  grammes  a 
day)  by  man  with  comparative  impunity.  It  must  be  added  that 
the  above  interesting  laboratory  experiments,  conclusive  as  they 
seem  to  be  to  their  author,  who  has  full  faith  that  he  has  now  found 
a  sure  specific  for  cholera,  still  lack  clinical  confirmation  which 
comes  from  a  series  of  carefully  conducted  experiments  on  animals 
(Boston  Medical  and  Surgical  Journal,  February  7,  1889). — Thera- 
peutic Gazette,  March  1889. 

The  Therapeutic  Action  of  Hyoscine. — In  the  Thera- 
peutische  Monatshefte  for  January  1889,  Dr  Kuy  of  Strasburg 
reports  the  results  of  the  administration  of  the  muriate  of  hyoscine 
in  subcutaneous  injections  in  eighty-eight  different  cases  occurring 
in  the  Strasburg  clinic  for  nervous  disease.  In  82-2  per  cent,  the 
result  was  successful,  sleep  lasting  from  six  to  eight  hours,  occurring 
within  an  hour  after  the  administration  of  the  dose.  The  majority 
of  failures  occurred  in  cases  where  the  insomnia  was  not  accom- 
panied by  any  motor  disturbances  ;  while,  on  the  other  hand,  where 
there  were  marked  motor  symptoms,  as  in  mania  and  paralysis,  the 
result  was  the  most  favourable.  The  dose  was  from  ^k^  to  ^V  gr., 
although  sometimes  the  dose  had  to  be  increased  on  account  of  the 
patient  becoming  accustomed  to  the  drug.  One-twentieth  of  a 
grain  a  day  was  the  largest  amount  ever  given.  Disagreeable 
after-effects  were  seldom  observed,  and  these  consisted  of  dryness 
of  the  throat  and  thirst.     Heart  disease  does  not  appear  to  be  a 


1889.J  MONTHLY  REPORT  ON  THERAPEUTICS.  1065 

contraindication  for  its  use,  since  it  was  used  in  a  case  of  aortic 
insufficiency  with  good  result.  Tastelessness,  ready  solubility,  and 
cheapness  are  special  recommendations  for  the  drug.  Dr  Kuy  gives 
the  preference  to  hyoscine  for  a  hypnotic  in  cases  of  great  excite- 
ment, while  sulphonal  is  preferable  in  cases  of  insomnia  not  so 
accompanied  by  motor  disturbances.  In  paralysis  agitans  and 
multiple  sclerosis,  hyoscine  proved  to  be  a  palliative  remedy. — 
Therapeutic  Gazette,  March  1889. 

A  New  Antidote  for  Morphtne. — In  the  Internationale 
Klinische  Ilundschau  for  January  27,  1889,  Professor  Arpad  Bokai 
recommends  picrotoxine  as  an  antidote  for  morphine,  on  the  ground 
that  it  exerts  an  antagonistic  action  to  morphine  on  the  respiratory 
centres;  for  while  morphine  tends  to  paralyze  these  centres,  picro- 
toxine exerts  a  powerful  stimulating  effect.  Since,  therefore,  death 
in  morphine  poisoning  is  usually  attributable  to  paralysis  of  the 
respiratory  centre,  on  this  ground  alone  picrotoxine  should  be  indi- 
cated as  a  valuable  antidote.  Further,  morphine  may  produce  such 
rapid  reduction  in  blood-pressure  as  to  endanger  life,  while  picro- 
toxine, on  the  other  hand,  is  a  powerful  stimulant  to  the  vaso-motor 
centre,  and  is  in  this  respect  also  antagonistic  to  morphine. 
Professor  Bokai  adds,  that  the  action  of  morphine  on  the  cerebrum 
is  directly  opposed  to  that  exerted  by  picrotoxine.  Finally,  Prof. 
Bokai  suggests  that  the  previous  administration  of  a  small  dose  of 
picrotoxine  might  reduce  the  danger  of  asphyxia  in  chloroform 
narcosis. — Therajpeutic  Gazette,  March  1889. 


OCCASIONAL  PERISCOPE  OF  THE  DISEASES  OF 
CHILDREN. 

By  Charles  E.  Underhill,  M.B.,  F.R.C.P.E.,  Physician  to  the  Royal 
Hospital  for  Sick  Children. 

Retropharyngeal  Abscess. — This  is  not  a  very  common  con- 
dition, and  it  is  frequently  overlooked.  It  was  formerly  supposed 
to  be  almost  always  symptomatic  of  spinal  caries ;  but  more  recent 
inquiries  show  that  the  majority  of  cases  are  idiopathic,  and  occur 
in  infancy.  Bokai  in  two  papers  gives  statistics  of  upwards  of  200 
cases.  Of  these,  189  were  idiopathic,  and  were  almost  all  in  chil- 
dren under  two  years  of  age ;  7  were  subsequent  to  caries  of  the 
vertebrae,  and  7  more  were  due  to  burrowing  of  pus  from  abscesses 
in  the  neck.  In  97  cases  collected  by  Gautier  nearly  one-third  were 
in  infants  under  one  year.  The  eetiology  is  somewhat  obscure,  some 
authors  believing  that  the  abscesses  arise  from  a  species  of  lymph- 
adenitis ;  others  that  they  are  due  to  a  simple  phlegmonous  inflam- 
mation of  the  cellular  tissue  ;  others,  again,  that  they  are  the  result 
of  morbid  processes  occurring  in  either  the  mucous  or  serous 
membranes  of  one  of  the  cranial  cavities.     No  doubt  the  scrofulous 

EDINBURGH   MED.   JOURN..   VOL.    XXXIV.— NO.   XI.  6  T 


1066  PERISCOPE.  [may 

diathesis  is  a  predisposing  cause  in  a  very  large  number  of  cases, 
while  a  large  percentage  have  been  observed  to  occur  after  scarla- 
tina, measles,  and  other  specific  fevers ;  while  they  occasionally 
follow  catarrhal  inflammations  of  the  nose,  pharynx,  and  middle 
ear.  Tlie  symptoms  vary  greatly  in  intensity  according  as  the 
disease  is  primary  or  secondary,  acute  or  chronic.  In  acute  cases 
there  is  liigh  fever,  pain,  vomiting,  and  sometimes  convulsions.  In 
the  more  chronic  cases  the  onset  is  apt  to  be  insidious  and  the 
symptoms  indefinite.  They  may  resemble  catarrhal  laryngitis, 
membranous  croup,  oedema  of  the  glottis,  or  tonsillitis.  The  most 
important  diagnostic  signs  are  difficulty  of  deglutition,  dyspnoea, 
cougli,  and  a  marked  nasal  or  palatal  sound  in  the  child's  voice. 
This  should  always  lead  to  an  inspection  of  the  pharynx,  and  an 
exploration  with  the  finger  where  the  abscess  will  be  detected. 
Early  incision  with  a  guarded  knife  is  the  obvious  treatment.  The 
paper  contains  a  record  of  three  interesting  cases. — A.  D.  Blackadder, 
Arch,  of  Fediat.y  February  1889. 

Tumours  of  the  Brain  in  Children,  their  Variety  and 
Situation. — For  the  purposes  of  this  paper  the  author  has  collected 
the  records  of  300  cases  of  cerebral  tumours  occurring  in  persons 
under  the  age  of  19.  Many  of  the  cases  had  been  slowly  progress- 
ing for  several  years.  They  show  that  infants,  children,  and  youth 
are  about  equally  liable  to  develop  tumours  within  the  cranium ; 
while  males  are  more  liable  than  females  in  the  proportion  of  three 
to  two.  The  variety  of  tumours  is  great,  but  more  than  half  of  the 
whole  number  were  tubercular,  while  carcinomata  and  gummata 
were  very  rare.  Glioma  and  sarcoma  follow  tubercle  in  frequency, 
and  each  make  up  about  one- tenth  of  the  cases.  Cysts  are  not  un- 
fiequent.  Some  of  the  cases  of  carcinoma  were  secondary  to  the  same 
disease  in  the  eye.  The  difierentiation  of  the  kind  of  tumour  is 
very  difficult,  and  demands  a  careful  consideration  of  the  family  and 
special  history  of  the  cases,  and  of  any  coexisting  disease  elsewhere. 
As  to  the  situation  of  the  tumour,  the  parts  most  affected  in  child- 
hood are  the  cerebral  axis  and  the  cerebellum.  By  the  cerebral 
axis  is  meant  that  part  of  the  brain  which  includes  the  basal  ganglia 
and  the  internal  capsule,  the  corpora  quadrigemina  and  crura  cerebri, 
the  pons  and  medulla.  About  one-third  of  all  the  cases  involved  the 
cerebral  axis,  and  they  gave  rise  to  many  localizing  symptoms,  but 
these  are  not  dealt  with  in  this  paper.  There  were  96  tumours  of 
the  cerebellum  ;  tumours  in  this  situation  are  much  more  common 
in  children  than  in  adults,  and  their  diagnosis  is  not  difficult.  The 
general  symptoms  of  brain  tumour  are  fully  and  rapidly  developed, 
viz.,  headache,  mental  disturbance,  irritability  and  apathy,  vertigo, 
vomiting,  optic  neuritis  with  or  without  blindness,  and  possibly 
general  convulsions.  The  headache  may  be  referred  to  any  part  of 
the  head,  and  does  not  indicate  the  position  of  the  tumour ;  but 


1889.]     OCCASIONAL  PERISCOPE  OP  THE  DISEASES  OF  CHILDREN.      1067 

tenderness  on  percussion  over  the  occiput  is  a  valuable  sign  of 
cerebellar  disease.  The  local  symptoms,  which  are  of  great  im- 
portance, are  vertigo  and  cerebellar  ataxia — that  is,  a  staggering 
gait  and  tendency  to  fall  to  one  or  other  side  or  backwards.  The 
remaining  cases  are  tumours  of  the  cortex  and  tumours  of  the 
centrum  ovale,  56  in  number,  where  the  diagnosis  has  been  worked 
out  very  carefully  by  many  authors.  As  the  main  object  in  collect- 
ing these  cases  was  the  question  of  surgical  interference,  the  author 
takes  up  the  point  of  whether  it  would  have  been  possible  to  remove 
the  tumours  safely  in  any  of  the  cases  under  consideration.  Here 
the  position  of  the  tumour  is  all-important.  Those  lying  in  the 
cerebral  axis — one-third  of  the  cases — may  be  at  once  dismissed ; 
their  removal  is  impossible.  The  next  question  is,  Can  tumours  of 
the  cerebellum  be  removed  ?  Such  an  operation  lias  been  done, 
but  it  is  very  dangerous.  In  each  of  the  three  cases  which  the 
author  has  collected  the  child  died  within  forty-eight  liours.  But 
he  concludes  that  in  about  one-third  of  the  cases  of  cerebellar  tumour 
the  surgeon  can  reach  the  tumour :  that  the  operation  is  essentially 
exploratory,  that  it  is  more  dangerous  to  life  than  operations  upon 
the  cerebrum,  and  that  no  recoveries  have  as  yet  been  recorded. 
Multiple  tumours  are  also  outside  of  the  field  of  operation  at  present. 
As  regards  tumours  in  the  cortex  and  centrum  ovale,  of  which  there 
were  5Q^  tlie  author,  having  tabulated  40  in  which  the  symptoms 
were  distinctly  and  sufficiently  localizing,  thinks  that  in  19  an 
operation  was  indicated,  and  in  16  of  them  it  would  have  been 
successful. — M.  Allen  Starr,  M.D.,  Medical  News  (Philadelphia), 
12th  January  1889. 

The  Influence  of  Sewerage  and  Water  Pollution  on  the 
Prevalence  and  Severity  of  Diphtheria. — No  single  cause 
has  as  yet  been  accepted  by  the  profession  as  producing  diphtheria. 
The  majority  believe  in  sewer  gas  as  the  efficient  agent ;  others, 
among  whom  is  the  author  of  this  paper,  think  undue  importance 
has  been  given  to  it  as  a  causative  factor.  In  order  to  test  this  he 
sent  a  list  of  questions  bearing  on  the  subject  to  a  number  of  medical 
men  practising  in  the  mountainous  Western  States,  Minnesota, 
Dakota,  Wyoming,  Montana,  California,  Kansas,  Utah,  and  Idaho. 
From  the  answers  he  received  he  adopts  the  following  conclusions ; 
— 1.  Diphtheria  occurs  in  the  mountains  and  prairies  of  the  great 
North-West  with  the  same  malignancy  as  in  cities.  2.  Diphtheria 
takes  place  with  equal  virulence  in  vicinities  remote  from  sewers. 

3.  Diphtheria  once  present,  the  inhabitants  living  in  damp  sod 
houses,  or  over  cellars  containing  decomposing  vegetables,  or  in 
proximity  to  manure  heaps  or  poorly  constructed  sewers,  seem  to 
be  in  surroundings  which  increase  the  severity  of  the  malady. 

4.  The  fact  is  again  demonstrated,  that  the  contagious  element  may- 
be carried  or  transported  thousands  of  miles  in  a  manner  difficult 


1068  PERISCOPE.  [may 

to  understand.  5.  The  poison  may  be  transported  by  means  of  cars 
and  steamers.  This  calls  for  more  efficient  means  of  disinfection, 
and  greater  care  than  has  yet  been  exercised  by  our  transportation 
companies.  6.  Tiiis  terrible  disease  being  so  contagious,  .... 
the  only  way  by  which  we  can  prevent  the  spread  of  diphtheria  is 
by  enacting  laws  compelling  the  people  to  assume  some  responsi- 
bility in  regard  to  contagious  diseases. — G.  Harrington  Earle,  M.D., 
Arch,  of  Pediat,  November  1888. 

In  the  same  journal  for  the  following  month  is  a  short  note  by  the 
same  author,  "Congenital  Steicture  or  Spasm  of  the  Urethra 
AS  A  Cause  of  Incontinence,  its  Cure  by  the  Sound."  In  any 
case  of  incontinence  which  resists  the  ordinary  remedies,  including 
any  necessary  attention  to  the  glans  and  prepuce,  the  urethra  should 
be  explored  by  the  sound.  A  cure  may  thus  be  readily  effected  in 
cases  which  have  been  abandoned  as  beyond  the  reach  of  cure. 
Three  cases  are  related  where  this  was  done  successfully.  There 
is  nothing  new  in  the  suggestion,  but  it  is  surprising  that  so  few 
authors  speak  of  stricture  as  a  cause  of  incontinence.  Everybody 
examines  the  glans  and  prepuce,  very  few  go  further  and  investi- 
gate the  condition  of  the  urethra.  It  is  not  every  case  that  has 
spasm  of  the  urethra,  but  many  have.  The  pathology  of  the  condition 
is  not  clearly  defined  and  is  not  discussed  fully,  as  the  paper  is  only 
intended  to  call  attention  to  some  clinical  facts. 


mxi  ^im^ 


MEDICAL    NEWS. 


Royal  Colleges  of  Physicians  and  Surgeons,  Edinburgh,  and  Faculty  op 
Physicians  and  Surgeons,  Glasgow. — The  following  candidates  passed  their  final 
examination  for  the  triple  qualification  in  Medicine  and  Surgery  at  the  sittings  held 
in  April  1889,  and  were  admitted  L.E.C.P  &.  S.  Ed.,  and  L.F.P.  &.  S.  Glasg. : — 
Harvey  Macpherson,  Cheltenham;  Siraon  Ryan,  Armagh;  Albert  Patrick  Coates, 
County  Galway  ;  Alfred  Robert  Sieveking,  Middlesex ;  Herbert  Edmund  Wright, 
Oldham;  Lionel  Selfe  Wells,  Australia;  John  Clarence  Auld,  Canada;  George 
Bridgeford  Proctor,  Birkenhead ;  Walter  Dowley  Eddowes,  Stamford ;  Robert 
Johnson  Pirie,  Dundee  ;  Walter  Clarence  Dyer,  Simla,  India ;  Andrew  Barron  Gass, 
County  Monaghan  ;  James  Maher,  County  Kilkenny ;  George  William  Johnstone, 
Edinburgh  ;  John  Francis  Butler-Hogan,  County  Cork  ;  John  Cornelius  O'SuUivan, 
County  Kerry;  Patrick  Francis  O'Hagan,  Longford;  Andrew  Morton,  Banbridge  ; 
Arthur  Bertram  Maclagan  Howard,  Benares ;  Charles  Gordon  Macleod,  Newport, 
Fife;  Francis  Wm.  Kane,  Mallow,  County  Cork;  John  O'Neill,  Glanworth,  County 
Cork;  Joseph  O'Brien,  Strabane ;  William  Charles  Robinson,  Broughshane;  Archibald 
Munday  Weir,  Malvern,  Worcestershire  ;  Stuart  Ryall  Blake,  Plymouth ;  James 
Anderson,  OrlofF,  Badulla,  Ceylon ;  Francis  William  Wingrove,  Victoria ;  Frederick 
M'Dowell,  Aldershot;  Henry  Martyn,  Fames,  Abergavenny;  Alfred  Murray  Gray, 
Douglas,  Isle  of  Man ;  John  Birtwhistle,  Griffiths,  Stroud ;  and  Henry  Augustus 
Lawson,  Sligo. 


1889.]  MEDICAL  NEWS.  1069 

RoYATi  CoixEGE  OF  SoRGEONS,  EDINBURGH. — The  followiiig  gentlemen  passed  their 
final  examination  for  the  degree  in  Surgery  at  the  sittings  held  in  April  1889,  and 
were  admitted  L.E.C.S.  Ed.  : — Inglis  Taylor,  Melbourne;  and  Marcus  Marwood 
Bowlan,  Newcastle-on-Tyne. 

KovAL  College  of  Physicians,  Edinburgh. — The  following  gentlemen  passed 
their  final  examination  for  the  degree  in  Medicine  at  the  sittings  held  on  6th  April 
1889,  and  were  admitted  L.  R.C.P.  Ed.  : — Richard  Thomas  Dundas,  Enniskillen  ; 
William  John  Douglas,  Ontario,  Canada  ;  William  Francis  Copley  Woodhead,  Leeds ; 
Walter  Gray,  North  Devon. 

The  following  is  the  official  list  of  candidates  who  passed  the  first  professional 
examination  in  Medicine  at  Edinburgh  University  in  March  1889  : — A.  T.  Anderson, 
W.  C.  Anderson,  G.  J.  Bagram,  T.  B,  Barber,  W.  D.  Barrow,  J,  S.  Bateson, 
Alexander  Baxter,  George  Bell,  J.  B.  Bell,  W.  B.  Bell,  C.  C.  Bird,  James  Blyth,  C.  H. 
Bond,  Laurence  Bowman,  A.  S.  Boyd,  Alexander  Bremner,  J.  C.  Brown,  W.  S. 
Bruce,  W.  M.  Brunton,  A.  \V.  Cameron,  James  Cameron,  P.  N.  Carmichael,  J.  G. 
Ciittanach,  J.  M.  Christie  (M.A.),  G.  P.  Coldstream,  R.  A.  Corson,  James  Cowie, 
George  Crarer,  J.  F.  Crombie,  V.  M.  Daly,  R.  P.  Dawson,  C.  B.  Dobell,  J.  Q. 
Donald,  W.  E.  Douborg,  D.  C.  Edington,  Thomas  Fentem,  A.  A.  Fermie,  Andrew 
Fernie,  William  Fitzgerald,  A.  W.  Forrest,  J.  R.  Foster,  G.  A.  Fothergill,  D.  P. 
Foulkes,  R.  A.  Fox,  Charles  Frier,  Antonius  Gorgian,  S.  D.  Graham,  John  Grieve, 
T.  C.  Guthrie,  W.  T.  Hall,  W.  M.  Halliday,  J.  A.  Hamilton,  A.  H.  Hopkins,  E. 
C.  W.  Hughes-Games,  F.  H.  Humphris,  S.  P.  Hyam,  George  Johnstone,  L.  B.  Keng 
(with  distinction),  Robert  Knox,  George  Lane,  A.  W.  V.  Livesay,  H.  C.  Lloyd,  P. 
V.  Locke,  A.  H.  Lowe,  G.  O.  M.  Lunt,  W.  F.  Macarthur,  Malcolm  M'Callum, 
Alexander  Macdonald,  James  Macdonald,  Alexander  M'Ewan,  F.  W.  Mackay, 
William  M'Lean,  W.  G.  M'Neil,  J.  C.  Mitchell,  A.  J.  Nevett,  George  Newman, 
P.  W.  Nicol,  H.  D.  Nutall,  L.  J.  H.  Oldmeadow,  John  Owens,  G.  W.  Park,  Charles 
Parker,  William  Peart-Thomas,  A.  W.  Peebles,  W.  H.  Pritchard,  Albert  Reid, 
Robert  Rendall,  Alister  Robertson,  William  Robertson,  William  N.  Robertson, 
Edward  Robinson,  L.  N.  Robinson,  R.  H.  Ross,  W.  A,  Rutherford,  J.  D.  Saner, 
Raoul  Scheult,  J.  A.  Scott,  R.  W.  L.  Scott,  Alexander  Selkirk,  St  John  Stanwell, 
R.  R.  Stitt,  A.  G.  Talbot,  J.  R.  Taylor,  Charles  Telfer,  A.  J.  A.  Theobalds,  Cuthbert 
Thompson,  W.  K.  W^alker,  John  Wallace,  Francis  Ward,  D.  C.  Watson,  Victor 
WerdmuUer,  W.  J.  White,  J.  C.  Wilson,  J.  M.  WUson,  and  C.  N.  Winch. 

Fletchers'  Hydrobromates  (Syrup  Ferri  et  Quinite  et  Strychnige 
Hydrobrom). — We  have  received  from  Messrs  Fletcher,  Fletcher, 
&  Stevenson,  London,  a  specimen  of  this  syrup  put  up  in  original 
bottles  ready  for  dispensing,  and  have  much  pleasure  in  recom- 
mending them  to  the  favourable  notice  of  the  profession. 

Phenacetin. — We  have  received  from  Burroughs,  Wellcome,  & 
Co.,  Tabloids  of  Compressed  Phenacetin,  each  containing  5  grains 
in  addition  to  a  little  saccharin,  which  appears  to  mask  the  taste  of 
the  drug.  We  can  highly  recommend  these  "  tabloids  "  as  a  power- 
ful antipyretic. 

New  Inventions. — 1.  Dr  Ward  Cousins'  3-dram  Eectal  Fluid 
Injector.  This  instrument  is  intended  for  injecting  into  the  rectum 
glycerine,  oil,  and  other  remedies,  also  beef-tea  and  other  nutrients. 
It  is  admirably  adapted  for  the  purpose.  2.  Dr  Ward  Cousins' 
Ointment  Injector.  This  is  a  very  ingenious  instrument  for  in- 
jecting ointments  into  the  rectum.  It  is  simple  and  efficacious. 
Both  instruments  are  manufactured  and  sent  us  by  Burroughs, 
Wellcome,  &  Co.,  London. 


mo 


MEDICAL  liEWS. — OBITUARV. 


[may 


Natural  Mineral  Water  of  "La  Bourboule"  (Puy-de- 
Dome). — We  have  received  from  Messrs  Ingram  &  Eoyle,  London, 
a  specimen  of  this  natural  arsenical  mineral  water,  and  having  had  an 
opportunity  of  trying  it  in  a  bad  case  of  pernicious  anaemia,  we  are 
able  to  state  that  it  is  a  powerful  remedy  in  such  cases.  The 
arsenic  exists  in  the  water  in  the  form  of  arseniate  of  soda  (1'96 
grains  per  gallon). 

In  this  water  the  arsenic  salt  is  in  a  form  very  easily  assimilated. 
In  addition  to  this  powerful  salt  the  water  contains — 

per  litre. 


Chloride  of  Sodium, 

198-842 

„          Potassium, 

11-361 

>} 

„          Lithium,     . 

trace. 

„          Magnesium, 

2-240 

>) 

Bicarbonate  of  Sodium, 

202-440 

}i 

„             Calcium, 

13-335 

»> 

Sulphate  of  Sodium,     . 

14-588 

» 

Peroxide  of  Iron, 

0-147 

)> 

Protoxide  of  Manganese, 

trace. 

Silicic  Acid, 

8-400 

» 

Alumina,     . 

trace. 

Organic  matter,    . 

. 

trace. 

These  mineral  constituents  are 

also  most  v 

aluable  in 

all  cases  of 

angemia.     This  mineral  water  is 

sure  to  beco 

me  extensively  used,  as 

it  is  undoubtedly  a  most  powerful  therapeuti 

c  agent. 

OBITUARY 

^. 

JAMES  MACLAREN,  F.R.C.S.E. 

It  was  with  sincere  regret  that  all  who  knew  him  received  the 
news  of  the  sudden  and  early  death  of  Dr  James  Maclaren,  Medical 
Superintendent  of  the  Stirling  District  Asylum,  which  took  place  at 
Larbert  on  the  25th  March. 

Dr  Maclaren  was  born  at  Ashby-de-la-Zouche  in  1849.  He 
received  his  early  education  at  the  Crieff  Academy  and  the  High 
School  of  Edinburgh.  He  obtained  his  medical  qualifications,  and 
immediately  thereafter  his  first  professional  appointment — that  of 
Resident  Physician  in  the  Royal  Hospital  for  Sick  Ciiildren,  Edin- 
burgh— in  the  year  1872.  In  1873  he  was  the  first  assistant 
appointed  by  Dr  Clouston  when  that  gentleman  became  Physician 
Superintendent  of  the  Royal  Edinburgh  Asylum,  he  and  Dr 
Clouston  entering  upon  their  respective  offices  on  the  same  day. 
He  rapidly  rose   to  the  position  of  Senior  Assistant  Physician  at 


1889.]  JAMES  MACLAREN.  1071 

Morningside.  In  1876  he  was  appointed  to  succeed  the  late  Dr 
Frederick  Skae  as  Superintendent  of  the  District  Asylum  at 
Larbert.  This  position  he  held  until  his  death.  Dr  Maclaren 
had  been  in  delicate  health  for  a  long  time  previous  to  his  last 
illness,  and  four  days  before  his  death,  at  a  meeting  of  the  District 
Board  which  he  himself  was  able  to  attend,  he  was  granted  two 
months'  leave  of  absence. 

Dr  Maclaren's  individuality  in  asylum  administration,  and  his 
comprehensive  grasp  of  the  details  of  the  specialty  to  which  lie  had 
devoted  his  life,  were  among  the  most  striking  characteristics  of  his 
professional  career.  He  brought  to  bear  upon  the  routine  of  his 
daily  work  not  only  his  medical  skill,  but  his  extensive  and 
general  erudition. 

When  he  entered  upon  the  duties  of  his  office  at  Larbert  the 
Asylum  was  not  half  as  large  as  it  now  is.  He  had,  therefore,  to 
contend  for  years  with  the  difficulties  of  an  overcrowded  institu- 
tion. The  measures  which  he  adopted  for  the  alleviation  of  this 
evil  were  bold  and  original.  All  the  partitions  of  corridors  within 
the  building  were  removed,  and  the  interior  of  each  ward  was 
extended  from  wall  to  wall.  The  result  was  that  communication 
from  the  dining-rooms  and  administrative  parts  of  the  Asylum  was 
only  through  the  wards.  The  slight  inconvenience  of  this  arrange- 
ment was  completely  lost  sight  of  in  the  immediate  relief  which  the 
larger  space  and  greater  freedom  gave  to  the  inmates.  He  was 
afterwards  engaged  in  the  construction  of  an  additional  block, 
which  of  its  kind  is  second  to  none  in  the  kingdom  for  cheapness, 
utility,  and  comfort. 

As  a  public  man  Dr  Maclaren  was  widely  respected,  and  his 
public  services,  such  as  the  delivery  of  addresses  and  presiding  at 
meetings,  were  much  sought  after.  He  was  a  very  able,  cultured, 
and  happy  speaker. 

He  was  selected  by  his  professional  brethren — the  members  of 
the  Stirling,  Kinross,  and  Clackmannan  Branch  of  the  British 
Medical  Association — to  be  their  first  President,  and  his  presidential 
address,  delivered  at  Larbert,  on  "The  Aims  and  Objects  of  Branch 
Associations,"  was  much  appreciated  by  all  who  listened  to  it. 

Dr  Maclaren  was  a  student  of  history,  and  was  well  read  in 
it,  both  ancient  and  modern.  The  light  which  this  knowledge 
enabled  him  sometimes  to  throw  upon  the  study  of  psychology 
was  interesting  and  valuable. 

He  contributed  many  papers  to  this  and  various  other  medical 
journals,  chief  of  which  were  articles  on  Chorea,  Impulsive  Insanity, 
Epilepsy  and  Insanity,  and  on  Infantile  Paralysis.  His  literary 
style  was  graceful  and  polished. 

He  was  40  years  of  age.  He  has  left  a  widow  and  two  young 
daughters,  for  whom  much  sympathy  is  felt  by  a  numerous  circle 
of  friends. 


1072 


PUBLICATIONS   RECEIVED. 


[may  1889. 


PUBLICATIONS   RECEIVED. 


Wm.  Alexander,  M.D.,  F.R.C.S.,— The 
Treatment  of  Epilepsy.  Young  J.  Pent- 
land,  Edin.,  1889. 

T.  M'Gall  Anderson,  M.D.,— Syphilitic 
Afifections  of  the  Nervous  System.  James 
Maclehose  &  Sons,  Glasp;.,  1889. 

Hknuy  Asiiny,  M. D., — Notes  on  Physio- 
logy. Longmans,  Green,  &  Co.,  Lond., 
1889. 

Samuel  Benton,  L.H.C.P.,  etc.,— Fifteen 
Hundred  Cases  of  Fistula,  Piles,  etc. 
Henry  Renshaw,  Lond.,  1889. 

Harry  Campbell,  M.D.  etc., — The  Causa- 
tion of  Disease.    H.  K.  Lewis,  Lond.,  1889. 

Prof.  Charcot  (translatedbyA.de  Watte- 
ville,  M.D.), — On  the  Treatment  by 
Suspension  of  Locomotor  Ataxy.  David 
Stott,  Lond..  1889. 

T.  Christy,  F.L.S.,etc., — New  Commercial 
Plants  and  Drugs,  No.  11.  Christy  & 
Co.,  London,  1889. 

Charles  Creighton,  M.D., — Jenner  and 
Vaccination.  Swan  Sonnenschein  &  Co., 
Lond.,  1889. 

Ridley  Dale,  M.D.,  etc., — Epitome  of 
Surgery.     H.  K.  Lewis,  London,  1889. 

Durham  University  Calendar  for  1889. 
Andrews  &  Co.,  Durham,  1889. 

Wm.  Ewart,  M.D., — The  Bionchi  and 
Pulmonary  Bloodvessels.  J.  &  A. 
Churchill,  Lond.,  1889. 

Austin  Flint,  M.D.,  LL.D., — A  Text-Book 
of  Human  Physiology.  H.  K.  Lewis, 
London,  1889. 

Frank  P,  Foster,  M.D., — An  Illustrated 
Encyclopaedic  Medical  Dictionary,  Vol.  I. 
Thomas  Sealey  Clark  &  Co.,  London,  1888. 

W.  T.  Gairdner,  M.D.,  LL.D.,— The 
Physician  as  Naturalist.  James  Maclehose 
&  Sons,  Glasg. ,  1889. 

Prof.  D.  J.  Hamilton, — A  Text-book  of 
Pathology.  Vol.  I.  Macmillan  &  Co, 
Lond.,  1889. 

H.  a.  Hare,  B.Sc,  M.D.,— Pathology, 
Clinical  History,  and  Diagnosis  of 
Affections  of  the  Mediastinum.  P. 
Blakiston,  Son  &  Co.,  Philadelphia,  1889. 

H.  Aubrey  Husband,  M.B.,  CM.,  etc.,— 
Student's  Handbook  of  Forensic  Medicine 
and  Public  Health.  E.  &  S.  Livingston, 
Edinburgh,  1889. 

Prof.  Joseph  Jones,  M.D., — Medical  and 
Surgical  Memoirs,  2  vols.  New  Orleans, 
1889. 

E.  Klein,  M.D.,  F.R.S.,— Elements  of 
Histology.     CasseU  &  Co.,  Lond.,  1889. 

Dr  J.-M.  Lavaux, — Du  lavage  de  la  vessie 
sans  sonde  a  I'aide  de  la  pression  atmo- 
sph^rique,  ses  usages — son  application  au 
traitment  des  cystites  douloureuses.  G. 
Steinheil,  Paris,  1888. 

I.  B.  Lyon,  F.C.S.,  F.  I.C.,— Text-book  of 
Medical  Jurisprudence  for  India.  Thacker, 
Spink,  &  Co.,  Calcutta,  1889. 

Sir  Wm.  MacCormac, — Surgical  Opera- 
tions.    Smith,  Elder,  &  Co.,  Lond.,  1889. 

G.  Macdonald,  M.D.,  —  Board-School 
Laryngitis.    A.  P.  Watt,  Lond.,  1889. 


E.  D.  Mapother,  M.D., — Papers  on  Derma- 
tology.    J.  &  A.  Churchill,  Lond.,  1889. 

Medical  Annual  and  Practitioner's  Index  for 
1889.     John  Wright  &  Co.,  Bristol,  1889. 

H.  DE  Mf  Ric. — Notes  on  Venereal  Diseases. 
Henry  Kenshaw,  Lond.,  1889. 

Wm.  MuRiiELL,  M.D.,  etc., — Massothera- 
peutics ;  or.  Massage  as  a  Mode  of  Treat- 
ment.    H.  K.  Lewis,  London,  1889. 

H.  Power,  M.B.,  and  L.  W.  Sedgwick, 
M.D., — The  New  Sydenham  Society's 
Lexicon  of  Medicine  and  the  Allied 
Sciences.     Edin.,  1889. 

Walter  Pye,  F.R.C.S.,— Elementary 
Bandaging  and  Surgical  Dressing.  John 
Wright  &  Co.,  Bristol,  1889. 

Reports  from  the  Laboratory  of  the  Royal 
College  of  Physicians,  Edinburgh.  Young 
J.  Pentland,  Edinburgh,  1889. 

S.  Rideal,  D.Sc, — Practical  Organic 
Chemistry.     U.  K.  Lewis,  Lond.,  1889. 

Saint  Thomas's  Hospital  Reports.  Vol. 
XVII.     J.  &.  A.  Churcliill,  Lond.,  1889. 

Robert  Sadndby,  M.D. ,  —  Lectures  on 
Bright's  Disease.  John  Wright  &  Co., 
Bristol,  1889. 

Emil  SchnAe,  M.D.,— Diabetes.  H.  K. 
Lewis,  Lond.,  1889. 

Prof.  Alex.  J.  C.  Skene,  M.D., — Treatise 
on  the  Diseases  of  Women  H.  K.  Lewis, 
Lond.,  1889. 

Otto  Spiegelberg. — A  Text-Book  of  Mid- 
wifery. New  Sydenham  Society,  London, 
1888. 

Transactions  of  the  American  Dermatological 
Association.     Boston,  1888. 

Transactions  of  the  American  Gynecological 
Society.  Vol.  XIII.  Wm.  J.  Dornan, 
Philadelphia,  1888. 

Transactions  of  the  American  Ophthalmo- 
logical  Society,  1888. 

Transactions  of  the  American  Surgical 
Association.    Vol.  VI.    Philadelphia,  1888. 

Transactions  of  the  Medical  Society  of 
Louisiana.     New  Orleans,  1889. 

Transactions  of  the  Obstetrical  Society  of 
London.     Part  IV.     Vol.  XXX. 

C.  Lloyd  Tuckey,  M.D., — Psycho-Thera- 
peutics. Bailliere,  Tindall,  &  Cox,  Lond., 
1889. 

Rev.  Isaac  Warren,  M.  A., — Warren's 
Table  Book,  containing  Tables  of  the 
Weights  and  Measures  used  in  the  British 
Empire,  etc.  Longmans,  Green  &  Co., 
Lond.,  1889. 

Sir  Spencer  Wells,  Bart.,  F.R.C.S.,— The 
Morton  Lecture  on  Cancer  and  Cancerous 
Diseases.    J.  &  A.  Churchill,  Lond.  1889. 

E.  G.  Whittle,  M.D., — Congestive  Neur- 
asthenia.    H.  K.  Lewis.  Lond.,  1889. 

Dr  Lewis-Nicholas  Wokthington,  — 
Chimie  inorganique  et  organique  botan- 
ique,  zoologie.     A.  Davy,  Paris,  1889. 

Dr  Lewis-Nicholas  U'orthington.  — 
Thdrapeutique ;  ligatures  des  art^res  ; 
trach^otomie  et  laryngotomie.  A.  Davy, 
Paris,  1889. 


OKIGINAL    COMMUNICATIONS. 

I.— THE  HARVEIAN  ORATION  FOR  1889 :  Delivered  12th 

April. 

By  J.  Bell  Pettigrew,  M.D.,  LL.D.,  F.R.S.,  F.R.C.P.,  Laureate  of  the 
Institute  of  France ;  Chandos  Professor  of  Medicine  and  Anatomy,  and 
Dean  of  the  Medical  Faculty,  University  of  St  Andrews,  etc.,  etc. 

(  Continued  from  page  998. ) 

In  1533  A.D.  the  Spanish  physician  Michael  Servetus  gave  to 
the  world  his  work,  De  Christianisimi  Restitutione  (Restoration  of 
Ch^'istianity),  a  volume  memorable  for  the  first  strong  light  it  threw 
on  the  circulation.  Servetus,  also  known  as  Villanueva,  was  a  man 
of  good  family,  born  in  1509  A.D.,  in  the  old  Spanish  kingdom  of 
Aragon.  He  had  a  chequered  and  eventful  career.  Educated  for  the 
Church  he  took  to  law,  and  in  the  earlier  part  of  his  life  figured  as 
a  courtier,  a  reformer,  and  a  journalist.  Latterly  he  studied 
Medicine  at  Paris  under  Jacobus  Sylvius  and  Winther  of  Ander- 
nach,  whose  prosector  in  anatomy  he  became,  having  for  his 
colleague  the  renowned  Vesalius.  Servetus  graduated  in  Medicine 
and  Arts  in  due  course,  and  displayed  during  his  all  too  brief  career 
great  independence  and  vigour  of  thought,  and  quite  an  extra- 
ordinary degree  of  physiological  instinct  and  insight.  He  was  an 
advanced  theologian  as  well  as  an  advanced  anatomist  and 
physiologist. 

Servetus  is  to  be  regarded  as  the  actual  discoverer  of  the  circula- 
tion of  the  blood  through  the  lungs ;  and  not  only  so,  he  had  a 
correct  if  limited  idea  of  the  chemical  changes  which  the  blood 
underwent  in  the  lungs  and  by  which  it  is  purified.  After 
explaining  that  the  source  of  the  blood  is  in  the  right  ventricle 
of  the  heart,  and  that  the  vital  spirit  represents  the  most  subtle 
part  of  the  blood  and  of  the  air  which  insinuates  itself  into  the 
lungs,  he  observes  : — "  But  the  communication,  that  is  to  say,  the 
passage  of  the  blood  from  the  right  to  the  left  ventricle,  does  not 
take  place  across  the  middle  septum,  as  persons  have  generally 
imagined  ;  it  depends  upon  a  more  singular  structure.  In  the  long 
winding  of  the  lungs  this  subtle  blood  is  agitated,  and  prepared  by 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV.— NO.    XII.  6  U 


1074  PKOFESSOR   PETTIGREW'S   HARVEIAN   OKATIOX.  [jUNE 

the  action  of  the  viscus  (the  lungs),  and  gains  a  yellow  colour. 
From  the  vena  arteriosa  (pulmonary  artery)  it  passes  into  the 
arterice  venosce  (pulmonary  veins),  where  it  becomes  mingled  with 
the  air  that  has  entered  the  lungs,  and  loses  its  fuliginous  excre- 
ments. Lastly,  it  enters  the  left  ventricle,  which  attracts  it  in  its 
diastole.  Such  is  the  preparation  of  the  blood  from  which  the 
vital  spirit  is  formed.  This  preparation  and  this  passage  from  the 
arterial  vein  (pulmonary  artery)  into  the  venous  artery  (pulmonary 
vein)  are  evidently  proved  by  the  size  of  the  vessels,  which  would 
not  be  so  large,  nor  possess  so  many  branches,  nor  carry  so  great  a 
volume  of  blood  to  the  lungs,  if  it  were  merely  designed  for  the 
nutriment  of  the  viscus"  (lungs).  He  further  states,  that  the 
vital  spirit  (which  in  this  case,  doubtless,  means  the  purified 
blood)  is  sent  by  the  left  ventricle  into  all  the  arteries  of  the 
body. 

These  passages  prove  clearly  enough  that  Servetus  had  not  only 
a  knowledge  of  the  circulation  of  the  blood  through  the  lungs,  but 
also  a  more  or  less  correct  notion  of  the  chemical  changes  which 
the  blood  undergoes  in  the  lungs.  The  blood  is  said  to  acquire  a 
yellow  colour,  and  to  lose  its  fuliginous  excrements;  in  other  words, 
its  sooty,  effete  matters.^  It  is  not  a  little  remarkable  that,  with 
the  brilliant  lead  of  Servetus,  so  many  celebrated  anatomists  and 
physiologists  should  have  intervened  between  himself  and  Harvey 
before  the  splendid  generalization  of  a  complete  pulmonic  and 
systemic  circulation  should  have  been  made. 

Servetus  was  a  restless,  finely-strung  genius,  of  extraordinary 
penetration  and  power;  and  had  his  life  been  spared,  there 
is  no  height  in  anatomy  and  physiology  to  which  he  might 
not  have  attained.  Unfortunately  for  himself,  he  had  a  very 
decided  leaning  to  theological  speculation — the  most  dangerous  of 
all  hobbies  in  his  day.  Having  fallen  under  the  ban  of  the  Church, 
which  he  had  hoped  to  elevate  and  purify  by  his  writings,  he  was 
persecuted  at  the  instigation  of  Calvin,  and  perished  miserably  at 
the  stake  in  1553  A.D.,  in  the  44th  year  of  his  age.  The  memory 
of  Servetus  alike  claims  our  admiration  and  regard — it  might 
almost  be  added,  our  homage — for  he  certainly  was  one  of  the 

^  Dr  Richard  Lower,  an  English  physician  born  1631  a.d.,  was  the  first  fully 
to  explain  the  effect  which  the  air  has  on  the  colour  of  the  blood.  He  proved 
by  experiments  on  dogs  that  the  florid  colour  of  the  arterial  blood  is  not  due 
to  the  action  of  the  heart  or  any  straining  it  undergoes  in  the  lungs,  but  to  the 
action  of  the  air  inspired.  Dr  Lower  opened  the  chest  of  a  living  dog,  and 
showed  that  the  blood  in  the  pulmonary  artery  is  as  dark  in  colour  as  that  in 
the  vena  cava.  He  then  cut  off  the  supply  of  air  from  the  lungs  by  placing  a 
ligature  round  the  trachea.  Under  these  circumstances  the  blood  which  flows 
from  the  aorta  is  no  longer  crimson,  its  usual  colour,  but  a  darJi  colour  similar 
to  that  in  the  pulmonary  artery  and  vena  cava.  On  readmitting  the  air  into 
the  lungs  by  untying  the  ligature  investing  the  trachea,  the  florid  colour  of  the 
blood  in  the  aorta  returns. — (Tractatus  de  Gorde :  item  de  Motu  et  Sanguinis  et 
de  Chyli  in  eum  transitu.     12mo.     London,  1669,  p.  170.) 


1889]  PROFESSOR  PETTIGREW'S   HARVEIAN   ORATION.  1075 

noble  band  of  martyrs  who  have  forfeited  their  lives  in  the  cause 
of  progress  and  truth. 

In  the  year  1487  A.D.,  Johannes  Guinterius,  otherwise  called 
Winther,  was  born  at  Andernach,  Cologne.  He  published  a  valu- 
able work  on  Anatomy  in  1536  a.d.,  and  was  the  first  to  indicate 
the  importance  of  the  pancreas,  to  point  out  the  complicated  nature 
of  the  spermatic  artery  and  vein,  to  demonstrate  the  bilateral 
nature  of  the  uterus,  and  to  explain  the  physiology  of  the  sphincter 
at  the  neck  of  the  bladder.  The  heart,  according  to  Winther,  is  a 
muscular  organ,  composed  of  superposed  fibres  running  longitudin- 
ally, obliquely,  and  transversely,  as  in  the  intestines,  bladder,  and 
uterus.  The  contraction  of  the  longitudinal  fibres  of  the  heart, 
in  his  opinion,  produces  the  diastole,  that  of  the  circular  fibres 
the  systole,  the  oblique  fibres  by  their  contraction  giving  the  ven- 
tricles a  rest,  at  which  moment  the  excrementitious  matters  of  the 
blood  escape  with  the  breath.  Winther  believed  the  septum  ven- 
triculorum  to  be  porous.  He  accurately  describes  the  mitral,  tri- 
cuspid, and  semilunar  valves,  and  declares  that  their  relations  to 
the  great  orifices  of  the  heart  are  such  that  they  permit  ingress  on 
the  one  hand,  and  oppose  egress  on  the  other.  Speaking  of  the 
respiratory  organs,  he  remarks : — "  The  air  taken  into  the  lungs 
when  breathing  undergoes  a  change  by  coming  into  contact  with 
the  vascular  network  of  the  vcTia  arteriosa  (pulmonary  artery) 
proceeding  from  the  right  side  of  the  heart,  and  of  the  arteria  venosa 
(pulmonary  vein)  sent  from  the  left,  interwoven  as  they  are  with 
the  minute  ramifications  of  the  proper  air-vessel,  the  trachea." 
Winther  had  as  pupils  and  anatomical  prosectors  Servetus  and 
Vesalius,  and  no  doubt  owed  much  to  the  sagacity  and  philo- 
sophical acumen  of  both. 

John  Dryander  or  Eichmens,  some  years  the  junior  of  Winther, 
threw  considerable  light  at  this  period  on  the  relations  subsisting 
between  the  cortical  and  medullary  substance  of  the  brain.  He 
also  traced  the  olfactory  nerves,  misnaming  them  optic  nerves. 

Contemporary  with  Servetus,  Winther,  and  Dryander,  was  the 
famous  Andrew  Vesalius,  on  the  whole  the  most  illustrious  anatomist 
of  the  sixteenth  century.  Vesalius  was  born  at  Brussels  in  1512  a.d., 
and  studied  medicine  at  Paris,  where,  in  conjunction  with  Servetus, 
he  acted  as  anatomical  prosector  to  Winther.  His  large  and  im- 
portant work  on  Anatomy  was  splendidly  illustrated.  Indeed,  his 
magnificent  anatomical  plates,  full  of  nature  and  art,  may  be  said 
to  have  clothed  anatomy  as  with  a  wedding  garment,  and  to  have 
stimulated  the  study  of  this  subject,  not  only  amongst  professional 
and  scientific  men,  but  also  amongst  scholars  and  outsiders  generally. 
It  is  due  to  the  reputation  of  Vesalius  to  state,  that  his  anatomical 
plates  have  never  been  surpassed  either  as  works  of  art  or  as 
correct  representations  of  actual  dissections. 

Dr  William  Hamilton  says  of  Vesalius,  that  "  he  appeared  like 
a  star  of  the  first  magnitude  amid  a  galaxy  of  minor  luminaries." 


1076  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [jUNE 

Vesalius  was  a  born  anatomist.  He  had  an  enormous  capacity  for 
details  and  facts,  and  added  very  largely  to  our  knowledge  on 
various  important  points  in  anatomy.  While  the  anatomy  of 
Vesalius  was  very  strictly  his  own,  his  physiology  was  essentially 
that  of  Galen,  for  whom  he  entertained  the  highest  esteem.  His 
physiology,  curiously  enough,  was  not  much  modified  by  the  brilliant 
inductions  of  his  friend  and  colleague  Servetus. 

Vesalius  and  Servetus  were  two  essentially  different  men. 
Vesalius  was  industrious,  conscientious,  and  matter  of  fact  to 
a  degree.  Servetus  scorned  restraint,  and  with  a  fervid  and 
brilliant  imagination  struck  truth  as  it  were  from  the  adamant. 
Vesalius  may  be  regarded  as  the  founder  of  modern  anatomy,  and 
Servetus  may  with  equal  propriety  be  regarded  as  the  founder  of 
modern  physiology. 

Vesalius  became  professor  of  anatomy  at  Padua  in  1537  A.D., 
and  was  soon  after  appointed  physician  to  the  Emperor  Charles 
V.  and  his  son  Philip  II.  of  Spain.  Following  his  great  master 
Galen,  Vesalius  regarded  the  heart  as  the  abode  of  the  soul  and 
of  the  emotions  and  passions,  the  hottest  of  the  viscera,  and  the 
distributor  of  heat  to  the  body.  The  heart  gave  rise  to  the  arteries, 
but  not  to  the  nerves ;  it  was  in  constant  motion,  alternately  dilat- 
ing and  contracting ;  it  was  furnished  with  valves,  more  or  less 
incompetent ;  the  right  side  of  the  heart  received  blood  from  the 
vena  cava,  which  is  transmitted  to  the  lungs  by  the  vena  arterialis 
(pulmonary  artery) ;  the  left  side  of  the  heart  received  blood  and 
air  from  the  lungs  by  the  arteria  venalis  (pulmonary  vein) ;  the 
septum  ventriculorum  was  solid  anatomically,  but  porous  physiolo- 
gically, to  comport  with  Galen's  views;  the  valves  of  the  heart 
had  analogues  in  the  veins — ostiola,  sometimes  called  eminences 
or  projections. 

The  blood,  according  to  Vesalius,  had  a  to-and-fro  movement, 
and  the  assumed  incompetency  of  the  cardiac  and  venous  valves 
favoured  this  view  ;  the  blood  in  the  veins  fed  the  tissues,  the 
blood  and  air  in  the  arteries  heated  the  body.  He  observes: — "So 
often  as  the  heart  dilates  the  right  ventricle  attracts  a  quantity  of 
blood  from  the  vena  cava,  which  it  concocts  and  attenuates  by 
its  heat,  and  so  makes  more  fit  to  be  carried  forward  by  the 
arteries." 

Again,  in  another  passage  he  remarks, — "  In  the  same  way  as 
the  right  ventricle  receives  blood  from  the  vena  cava,  does  the 
left  draw  in  air  from  the  lungs  through  the  arteria  venalis  (pul- 
monary vein)  for  the  purpose  of  tempering  its  native  heat." 
Pinning  his  faith  to  Galen,  he  concludes  "that  these  matters 
pertaining  to  the  function  of  the  heart  may  all  be  accomplished  in 
the  manner  set  forth  by  the  divine  man  "  (Galen). 

Vesalius  like  Servetus  had  a  miserable  end.  Having  performed 
a  post-mortem  examination  on  one  of  his  deceased  patients,  a 
young  nobleman,  a  foolish  and  ignorant  spectator,  declared  he  saw 


1889.]  PROFESSOR   PETTIGREW's   HARVEIAN   ORATION.  1077 

the  heart  of  the  dead  man  move  under  the  knife  of  the  anatomist. 
Vesalius  was  forthwith  indicted  for  murder,  not  only  before  the 
civil  tribunal,  but  also  the  Inquisition.  The  superstition  and  blind 
fury  of  the  judges  and  clergy  were  such  that  even  his  patron 
Philip  II.  failed  to  entirely  rescue  him.  He  was  sentenced  to 
undertake  a  pilgrimage  to  Jerusalem,  and  there  solemnly  confess 
a  crime  he  had  never  committed.  He  went  to  Jerusalem  never 
to  return,  having  been  wrecked  on  the  home  journey  at  the  island 
of  Crete,  where  he  died  of  starvation  and  under  great  privations. 

Vesalius  while  he  lived  had  as  friend  Realdus  Columbus,  a 
remarkable  man,  famed  like  himself  for  the  extreme  accuracy  of 
his  anatomical  researches.  Columbus  demonstrated  by  his  dissec- 
tions that  the  pleura  and  peritoneum  are  double  membranes.  He 
also  discovered  the  tunica  innominata  of  the  eye,  and  added  an 
important  additional  if  not  finishing  touch  to  the  circulation.  He 
traced  the  blood  from  the  vena  cava  through  the  right  side  of  the 
heart  and  through  the  lungs  to  the  left  ventricle  and  aorta,  and 
pointed  out  that  the  whole  of  the  hlood  and  not  the  vital  spirit 
only  passes  through  the  lungs.  In  this  respect  his  description 
of  the  circulation  is  an  advance  upon  that  given  by  Servetus, 
inasmuch  as  it  is  not  quite  certain  from  the  writings  of  the  latter 
that  all  the  blood  passed  through  the  lungs  on  its  way  to  the  left 
ventricle. 

The  lungs,  according  to  Columbus,  were  for  the  preparation 
and  elaboration  of  the  blood  and  the  vital  spirit.  He  fancied 
that  the  blood  was  attenuated  in  the  right  ventricle,  and  that  it 
was  further  attenuated  in  the  lungs,  where  it  was  mixed  up  with 
air  entering  the  trachea  and  bronchial  tubes.  Finally,  that  the 
blood  and  air  mixed  in  the  lungs  found  their  way  to  the  pulmonary 
veins,  and  were  ultimately  carried  to  the  left  ventricle  of  the 
heart.  Columbus  approached  indefinitely  near  to  the  explanation 
of  the  respiration  as  given  at  the  present  day.  His  mixture  of  blood 
and  air  in  the  respiratory  organs  was  simply  too  gross ;  he  should 
have  confined  his  description  to  the  passage  of  the  oxygen  of  the  air 
alone  into  the  blood. 

Among  those  who  contributed  to  advance  the  study  of  anatomy 
at  this  period  was  John  Philip  Ingrassias,  who  took  his  degree  of 
Doctor  of  Medicine  at  Padua  in  1539  a.d.  Ingrassias  discovered 
the  vesicular  seminales,  and  did  much  to  perfect  the  anatomy  of 
the  ear.  He  published  no  fewer  than  ten  medical  and  anatomical 
works,  and  was  most  successful  in  staying  the  plague  which  de- 
populated Palermo  in  1575  a.d. 

Another  of  the  anatomical  lights  of  the  sixteenth  century  was 
Gabriel  Pallopius,  born  at  Modena  in  1523  A.D.,  and  appointed 
professor  of  anatomy  to  the  School  of  Pisa  in  1548  a.d.  He  sub- 
sequently became  professor  of  anatomy  at  Padua.  Fallopius, 
great  as  an  anatomist,  had  also  a  wide  knowledge  of  medicine, 
botany,  astrology,  and  chemistry.     He  had  the  reputation  of  being 


1078  PROFESSOR   PETTIGIIEW'S   HARVEIAN   ORATION.  [jUNE 

most  methodical  in  his  teaching,  most  successful  in  his  healing, 
and  most  expeditious  in  dissecting.  His  anatomical  works  take 
a  high  place  in  medical  literature.  The  Fallopian  tubes  of  the 
uterus  are  called  after  him. 

Not  less  successful  as  an  anatomist  was  Bartholomew  Eusta- 
chius,  born  in  Italy  about  the  year  1520  a.d.  He  became 
professor  of  anatomy  at  Eome,  where  he  died  in  157-4  a.d.  His 
anatomical  plates  are  well  known,  and  his  anatomical  writings 
contain  a  number  of  important  discoveries.  He  did  much  to  the 
anatomy  of  the  renal  glands,  and  gave  an  accurate  description  of 
the  thoracic  duct.  He  discovered  the  passage  which  conducts 
from  the  throat  to  the  ear,  and  which  bears  his  name,  also  the 
valves  at  the  orifice  of  the  coronary  vein  and  vena  cava. 

In  1530  A.D.  Julius  Caesar  Arantius  was  born  at  Bologna,  where 
he  ultimately  became  professor  of  medicine,  anatomy,  and  sur- 
gery. He  devoted  much  attention  to  the  uterus  and  foetus.  He 
states  that  the  uterus  derives  its  blood  supply  from  the  spermatics 
and  hypogastrics,  and  that  the  substance  of  the  uterus  resembles 
a  sponge,  being  perforated  with  holes ;  further,  that  it  may  be 
divided  into  layers.  He  also  describes  the  foramen  ovale  and 
ductus  arteriosus  in  the  foetus,  and  explains  that  there  is  no 
communication  after  birth  between  the  right  and  left  ventricles 
of  the  heart,  the  blood  being  carried  through  the  lungs  by  the 
pulmonary  artery.  Arantius  as  well  as  Vesalius  was  aware  of 
the  existence  of  valves  in  the  veins,  and  the  little  nodules  in  the 
semilunar  valves  of  the  heart  are  designated  corpora  Arantii  in 
honour  of  him. 

In  the  year  1534  A.D.  Volcher  Goiter,  a  celebrated  pupil  both 
of  Fallopius  and  Eustachius,  was  born  at  Groningen.  He  studied 
at  Padua,  Eome,  Bologna,  and  Montpellier,  and  such  was  his  love 
for  anatomy  that  he  became  surgeon  to  the  French  army  with  a 
view  to  obtaining  more  subjects  for  dissection.  As  an  anatomist 
he  was  the  first  to  describe  the  corpora  lutea  of  the  ovaries,  and 
the  development  of  the  chick  in  the  egg.  He  believed  that  the 
auricles  of  the  heart  contract  after  and  not  before  the  ventricles. 
He  gave  elaborate  descriptions  of  the  frontal  sinuses  and  the  organ 
of  hearing,  and  discovered  the  corrugators  of  the  eyes  and  lips, 
and  the  manner  in  which  the  cartilages  and  bones  grow  in  the 
young  and  adult  skeleton. 

In  1566  A.D.  he  published  his  engravings  of  the  Cartilages ;  in 
1573  A.D.  appeared  his  External  and  Internal  Farts  of  the  Human 
Body,  with  plates  of  the  foetal  skull,  in  illustration  of  his  views 
on  the  growth  of  the  bones ;  and  in  1578  a.d.  his  fine  folio  volume 
of  Comparative  Anatomy,  with  figures  of  quadrupeds,  birds,  and 
amphibia,  was  given  to  the  world.  As  a  surgeon  he  directed 
attention  to  diseases  of  the  viscera,  and  explained  that  in  injuries 
to  the  head  the  danger  is  greatest  when  the  dura  mater  is  not 
lacerated.     In   such  cases  he  boldly  opened  that  membrane  to 


1889.]  PROFESSOK   PETTIGREW'S   HARVEIAN   ORATION.  1079 

let  the  extravasated  matter  escape.  He  also  pointed  out  that 
fungous  excrescences  of  the  brain  may  be  sliced  away  without 
risk. 

Next  in  order  comes  Constantius  Variolus,  a  native  of  Bologna. 
He  devoted  much  of  his  time  to  the  anatomy  of  the  brain,  and 
■was  the  first  to  point  out  that  the  medulla  oblongata  formed  part 
of  that  organ.  He  divided  the  encephalon  into  three  portions,  viz., 
the  cerebral  lobes,  the  cerebellum,  and  the  medulla  oblongata. 
He  discovered  the  transverse  process  of  the  brain  which  is  named 
after  him,  to  wit,  the  pons  Varolii;  also  the  glands  of  the  choroid 
plexus  and  the  ilio-csecal  valve. 

In  1519  A.D.  Cesalpinus  was  born  at  Areggo,  in  Tuscany,  and 
in  1571  A.D.  he  wrote  his  Peripatetic  QuestioTis.  In  his  fourth 
book  he  attributes  the  pulsation  of  the  arteries  to  an  effervescence 
of  the  blood  in  the  heart,  and  in  his  fifth  book  he  describes  the 
minor  circulation  through  the  lungs,  and  the  manner  in  which  the 
blood  passes  from  the  one  ventricle  of  the  heart  to  the  other. 
He  understood  the  nature  and  uses  of  the  valves,  and  drew  atten- 
tion to  the  fact  that  the  veins  swell  below  a  ligature.  He  all  but 
made  the  discovery  that  the  blood  of  the  arteries  returned  to  the 
heart  by  the  veins.  Believing,  however,  that  the  blood  flowed 
backwards  and  forwards  in  the  same  vessels,  he  missed  the  grand 
generalization.  He  had  a  curious  idea  that  the  blood  returned  to 
the  heart  during  sleep.  Not  the  least  interesting  part  of  the  labours 
of  Cesalpinus  was  the  important  discovery  of  the  different  sexes  of 
plants.  He  compared  the  seeds  of  plants  to  the  eggs  of  animals ; 
the  seed,  according  to  him,  protecting  and  nourishing  the  germ  or 
embryo  until  it  takes  root. 

The  next  name  of  note  is  that  of  Archangelo  Piccoluomini,  a 
native  of  Ferrara  and  a  citizen  of  Kome.  This  anatomist  had  a 
very  decided  leaning  to  physiology,  and  in  a  work  published  1573 
A.D.,^  promulgated  some  highly  interesting  views,  evidently  the 
result  of  original  observation.  Piccoluomini  first  drew  a  distinc- 
tion between  the  gray  and  white  matter  of  the  brain.  He  main- 
tained that  all  the  nerves  originated  in  the  medulla  oblongata ; 
regarded  the  alimentary  canal,  oesophagus,  stomach,  and  intestines 
as  different  parts  of  one  system — the  inner  or  mucous  lining  of  the 
bowels,  because  of  their  corrugations,  being  three  times  as  long  as 
the  outer  lining,  the  function  of  the  corrugations  being  to  detain 
the  chyle  so  as  to  admit  of  its  absorption  by  the  mesenteric  veins. 
He  showed  that  the  function  of  the  ileo-csecal  valve  was  to  prevent 
regurgitation  of  the  faeces  into  the  small  intestine.  He  first  de- 
scribed the  mesentery,  and,  like  Columbus,  maintained  that  the 
peritoneum  was  everywhere  double.  He  described  and  delineated 
the  anastomosis  of  the  vena  portae  and  vena  cava  within  the  liver, 

^  Anatomice  sive  de  resoluti :  one  corporis  humani  libri  quatuor.  8vo. 
Pataviae,  1673. 


1080  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [jUNE 

and  gave  an  exhaustive  account  of  the  tubuli  urinit'eri  of  the 
kidneys. 

One  of  the  last  to  add  an  important  increment  to  the  great 
subject  of  the  circulation  was  Hieronimus  Fabricius,  born  at  Aqua- 
pendente,  in  Tuscany,  in  1537  a.d.  He  was  the  pupil  and  suc- 
cessor, in  1563  A.D.,  of  the  celebrated  Fallopius  in  the  chair  of 
anatomy  at  Padua,  which  he  held  for  nearly  half  a  century, 
attracting  multitudes  of  pupils  by  his  eloquence,  erudition,  and 
high  moral  tone.  The  life  and  writings  of  Fabricius  are  invested 
with  a  very  peculiar  interest,  from  the  fact  that  the  immortal 
Harvey,  who  began  his  medical  studies  at  Padua  in  1598  a.d,, 
became  one  of  his  students,  and  there  is  reason  to  believe  drew 
not  a  little  of  his  own  inspiration  from  the  careful,  exhaustive,  and 
sagacious  teaching  of  his  talented  and  erudite  master. 

Fabricius  was  at  once  a  great  anatomist  and  a  great  surgeon,  and 
published  no  fewer  than  thirteen  works,  his  great  knowledge  of 
anatomy  enabling  him  to  introduce  many  important  improvements 
in  surgical  practice.  He  is  by  universal  consent  regarded  the 
father  of  modern  surgery,  Fabricius  did  especially  good  work  by 
his  studies  and  minute  inquiries  into  the  structure  and  uses  of  the 
valves  of  the  vascular  system.  As  already  explained,  the  exist- 
ence of  these  valves  was  known  to  Aristotle,  Erasistratus,  Galen, 
Sylvius,  Arantius,  Cesalpinus,  and  others.  Fabricius,  without  being 
fully  acquainted  with  the  literature  dealing  with  the  valves  of  the 
vascular  system,  directed  his  attention  more  especially  to  the 
valves  of  the  veins  in  a  treatise,  entitled  De,  venarum  ostiolis,  pub- 
lished in  1603  A.D.  While  previous  investigators  had  referred 
incidentally  to  the  valves  of  the  veins,  it  was  left  to  Fabricius  to 
give  the  first  clear  account  of  their  structure  and  uses,  and  to 
delineate  them,  Fabricius's  account  of  the  valves  of  the  veins, 
printed  in  1603,  had,  no  doubt,  an  important  influence  in 
fanning  the  flame  of  discovery  in  the  breast  of  Harvey,  who 
published  his  magnum  opus  On  the  Motion  of  the  Heart  and 
the  Blood  in  Animals  in  1628  a,d.,  exactly  a  quarter  of  a 
century  later. 

During  Harvey's  day  several  men  of  mark  came  to  the  front. 

Thus  in  1577  a.d.  the  well-known  John  Baptist  van  Helmont  was 
born  at  Brussels.  He  discovered  the  spirits  of  hartshorn,  the 
volatile  constituents  of  spa  waters,  and  other  substances  which 
exert  a  powerful  influence  on  the  animal  economy.  He  played  a 
principal  part  in  developing  the  chemical  school  of  medicine  as 
opposed  to  the  Galenical  school  with  its  four  elements,  four 
humours,  four  qualities,  and  four  degrees. 

In  1608  A.D.  at  Castelnuovo,  in  the  kingdom  of  Naples,  was  born 
the  distinguished  anatomist,  physiologist,  and  mathematician  John 
Alphonso  Borelli.  He  studied  at  Eome  under  Castelli.  Borelli 
in  the  earlier  part  of  his  career  devoted  himself  to  Medicine,  and 
wrote  a  treatise  on  the  nature  and  treatment  of  a  malignant  fever 


1889.]  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  1081 

which  nearly  depopulated  the  island  of  Sicily  during  the  years 
1647  and  1648  a.d. 

In  1656  A.D.  he  was  appointed  professor  at  Pisa,  and  became  a 
most  popular  lecturer.  He  was  a  prime  favourite  with  the  Grand 
Duke  Ferdinand  and  Prince  Leopold,  and  through  their  influence 
gained  a  seat  in  the  Academia  del  Cimento.  He  conceived  the  idea 
that  it  was  possible  to  explain  all  the  functions  of  the  animal  economy 
on  mathematical  principles,  and  in  this  way  endeavoured  to  account 
for  the  action  of  muscle,  the  several  movements  of  walking,  swim- 
ming, flying,  etc.  To  this  end  he  dissected  and  experimented 
largely.  The  outcome  was  his  thoughtful  and  splendidly  illus- 
trated volume,  De  motu  Animalium,  published  after  his  death  in 
1680  A.D.  Borelli  was  a  physiologist,  mathematician,  and  mechan- 
ician of  a  high  order.  He  invented,  among  other  things,  a  diving- 
bell,  and  a  submerged  boat  which  could  be  propelled  under  water, 
and  in  this  and  other  ways  showed  himself  to  possess  much  erudi- 
tion, ingenuity,  and  originality.  Like  other  geniuses,  he  died  poor, 
although  a  favourite  with  the  nobles,  and  specially  patronized  by 
Christiana  of  Sweden,  who  resided  at  Kome  towards  the  close  of 
his  career. 

In  1614  A.D.  Francis  de  la  Boe  Sylvius  was  born  at  Hainau. 
He  graduated  in  medicine  at  Basil  in  1637  A.D.,  and  in  1658  a.d. 
was  appointed  professor  of  medicine  at  Leyden.  Sylvius  espoused 
the  chemical  ideas  of  Van  Helmont,  and  insisted  that  disease  was 
the  result  of  an  excess  of  acids  or  alkalies  in  the  system,  and  that, 
in  order  to  effect  a  cure,  all  that  was  necessary  was  to  bring  about 
the  conditions  of  neutrality. 

About  this  time  Dr  Hugh  Chamberlen  improved  the  art  of 
midwifery  by  introducing  his  forceps,  and  male  accoucheurs  were 
employed,  especially  by  ladies  of  rank. 

In  1617  A.D.  the  justly  renowned  Sydenham  was  born  in 
Dorsetshire,  England,  and  in  1666  a.d.  he  published  his  Methodus 
Curandi  Febres  Propriis  Observationibus  Superstructa.  In  this  and 
subsequent  works  he  revived  the  inductive  method  of  reasoning 
employed  2000  years  before  by  Hippocrates.  Sydenham  was  a 
great  reformer  in  Medicine.  Brushing  aside  the  absurd  and  pre- 
conceived theories  of  Medicine  in  vogue  in  his  day,  he  returned  to 
a  careful  consideration  of  nature,  and  of  the  symptoms  and  rational 
treatment  of  disease,  having  regard,  as  far  as  was  possible,  to  the 
pathology  of  disease.  Sydenham  first  applied  his  inductive  method 
to  fevers,  then  to  measles,  gout,  dropsy,  small-pox,  hysteria,  calculus, 
and  other  disorders.  His  practice  and  writings  have  been  highly 
appraised,  and  the  latter  translated  into  various  European  lan- 
guages. 

The  year  1645  a.d.  was  memorable  as  witnessing  the  virtual 
beginning  of  the  now  famous  Eoyal  Society.  In  that  year  Francis 
Glisson,  the  professor  of  physic  at  Cambridge,  and  a  good  ana- 
tomist, was  in  the  habit  of  meeting  medical  and  other  scientific 

EDINBURGH   MED.    JOURN.,    VOL.    XXXIV. — NO.   XII.  6  X 


1082  PROFESSOR  PETTIGREW'S   HARVEIAN   ORATION.  [jUNE 

friends  weekly  in  London,  for  the  purpose  of  discussing  medical  and 
philosophical  subjects.  The  members,  chiefly  medical,  attending 
these  meetings  gradually  increased  in  numbers,  and,  after  the  Re- 
storation, were  incorporated  by  Eoyal  charter  under  the  title  of  the 
Royal  Society.  This  celebrated  Society  had  thus  a  medical  origin, 
and  it  is  well  to  bear  this  fact  in  mind  in  those  days  of  advanced 
and  aggressive  physicists.  Glisson  published  a  work  on  Rickets, 
and  wrote  learnedly  on  the  Liver.  He  discovered  the  cystic  duct, 
and  gave  an  accurate  description  of  the  capsule  of  the  vena  por- 
tarum,  hence  called  the  capsule  of  Glisson. 

In  1622  A.D.,  what  may  be  regarded  as  an  important  re-dis- 
covery, viz.,  that  of  the  lac  teals,  was  made  by  Gaspard  Aselli,  a 
native  of  Cremona,  who  taught  anatomy  with  much  acceptance  at 
Bologna.  In  this  year  (1622)  Aselli  happened  to  open  a  dog  after 
a  full  meal,  and  the  lacteal  vessels  being  distended  with  chyle 
were  distinctly  visible  as  they  ran  across  the  mesentery.  He  at 
first  mistook  them  for  nerves,  but  having  punctured  one  of  them, 
a  milky  substance  escaped,  which  convinced  him  they  were  vessels. 
In  order  to  ascertain  whether  these  vessels  existed  also  in  the 
human  subject,  he  administered  a  hearty  meal  to  an  unfortunate 
criminal  a  few  hours  before  execution,  and  had  the  satisfaction,  on 
opening  his  abdomen  immediately  after  death,  of  seeing  the  milk- 
white  lacteals  distended  with  chyle  wending  their  way  over  the 
bowels  and  mesentery.  Aselli  published  his  views  on  the  lacteals 
five  years  later,  viz.,  in  1627  a.d.^ 

While  Aselli  thus  directed  the  attention  of  anatomists  to  the 
existence  of  the  lacteal  vessels  in  man  and  beast,  he  apparently 
lacked  the  ability  to  follow  up  his  advantage.  He  fancied  the 
lacteals  terminated  in  the  liver,  and  confounded  them  with  the 
lymphatics  of  that  viscus.  He  further  mistook  a  collection  of 
mesenteric  glands  for  the  pancreas,  hence  called  pancreas  Aselli. 
In  reality,  the  lacteals  were  first  discovered  by  i\ristotle,  who,  as 
previously  stated,  likened  them  to  the  roots  of  plants.  Eustachius, 
moreover,  nearly  a  century  before  Aselli's  day,  observed  and 
described  the  track  of  the  lacteal  system,  now  known  as  the 
thoracic  duct. 

It  was  reserved  for  Pequet,  of  Dieppe,  to  demonstrate  the  course 
and  termination  of  the  lacteal  vessels  and  thoracic  duct.  This 
French  anatomist  traced  the  lacteal  vessels  from  the  intestines  to 
the  mesenteric  glands,  thence  to  a  common  reservoir,  which  he 
designated  the  receptacidum  chyli,  thence  via  the  thoracic  duct  to 
the  point  where  the  thoracic  duct  opens  into  the  vascular  system 
at  the  junction  of  the  jugular  and  subclavian  veins.  The 
lymphatics  of  the  body  generally  were,  curiously  enough,  dis- 
covered about  the  year  1651  a.d.  by  three  independent  investi- 
gators, viz.,  Rudbeck  of  Sweden,  Bartholine  of  Denmark,  and 
Joliffe  of  England.  The  exact  relations  of  the  lymphatics  to  the 
1  De  Venii  Lacteis.     4to.     Milan,  1627. 


1889.]  PHOF'ESSOR   PETTIGREW's    HAkVEIAN    OKATION.  1083 

lacteals  was  not  made  out  till  nearly  a  century  later  by  experi- 
ments instituted  in  the  school  of  the  Hunters. 

Prior  to  Pequet,  it  was  believed  that  the  chyle  was  absorbed  by 
the  mesenteric  veins,  and  conveyed  by  them  to  the  liver,  the  route 
by  the  lacteals  and  thoracic  duct  being  unknown. 

Aselli,  as  explained,  re-discovered  the  lacteal  vessels  in  1622 
A.D.,  his  treatise  on  the  subject  being  published  in  1627  a.d. 

A  year  later,  viz.,  in  1628  a.d.,  the  immortal  Harvey  gave  to  the 
world  his  great  work  entitled  An  Anatomical  Disquisition  on  the 
Motion  of  the  Heart  and  Blood  in  Animals,^  and  it  has  been  thought 
by  some  that  Harvey  did  not  attach  sufficient  importance  to  the 
new  system  of  vessels  demonstrated,  described,  and  delineated  by 
Aselli.  In  reality,  Harvey  was  aware  of  the  existence  of  the 
lacteal  vessels  from  his  own  dissections  of  the  lower  animals  before 
Aselli's  M^ork  appeared,  but  not  being  satisfied  as  to  their  function, 
and  not  regarding  them  as  an  essential  part  of  the  circulatory 
system,  he  did  not  feel  called  upon  to  follow  them  up.  He,  moreover, 
excused  himself,  on  the  ground  of  advancing  years,  from  under- 
taking what  would  virtually  have  been  a  new  and  extensive 
investigation. 

The  illustrious  Harvey,  whose  memory  we  are  met  this  evening  to 
honour,  was  born,  according  to  Willis,  on  the  1st  of  April  1578  a.d., 
some  authorities,  Dr  Omond,  e.g.,  fixing  the  date  at  the  12th  of  April, 
and  hence  our  Harveian  Festival  always  held  on  the  12th  of  the 
present  month.  He  died,  universally  regretted,  on  the  3rd  of 
June  1657.  Harvey  was  the  favourite  of  fortune  in  many 
ways.  He  belonged  to  an  old  and  influential  family.  His  father 
was  a  man  of  substance,  and  his  brothers  were  wealthy  London 
merchants.  He  had  time  and  money  always  at  command,  and 
never  lacked  opportunity.  Of  a  gentle,  thoughtful,  industrious, 
and  magnanimous  disposition,  he  quietly  worked  his  way  to  the 
first  place  in  medicine,  making  no  personal  enemies. 

His  career  is  most  interesting.  At  10  he  attended  the  Grammar 
School  of  Canterbury,  and  there  learned  the  rudiments  of  Latin  and 
Greek.  At  16  he  removed  to  Gonvil  and  Caius  College,  Cambridge, 
to  study  classics,  dialectics,  and  physics.  At  19  (1597  a.d.)  he 
took  his  degree  of  B.A.  and  quitted  the  university.  In  his  20th 
year  (1598  a.d.)  he  proceeded  to  the  University  of  Padua  in  Italy 
to  study  medicine  under  Fabricius,  Casserius,  Minadous,  and  other 
celebrated  teachers.  He  spent  four  years  at  this  renowned  seat  of 
learning,  and  in  1602  a.d.,  in  his  24th  year,  obtained  from  it  the 
diploma  of  Doctor  of  Physic.  On  returning  to  England  the  same 
year  (1602  a.d.)  he  also  received  the  Doctorate  in  Medicine  from 
the  University  of  Cambridge. 

In  1604  a.d.  he  joined  the  College  of  Physicians  of  London, 
being  made  a  Fellow  of  that  august  body  in  1607  a.d. 

^  Exercitatio  Anatomica  de  Motu  Cordis  et  Sanguinis  in  Animalibus.  Francf., 
1628. 


1084  rROFKSSOU   PETTIGREW's    HAKVEIAN    oration.  [JUNE 

In  1609  A.D.  he  was  appointed  Physician  to  St  Bartholomew's 
Hospital. 

In  1615  A.D.  he  had  the  honour  of  being  elected  the  Lumley  and 
Caldwell  Lecturer  in  anatomy  and  surgery  at  the  College  of 
Physicians,  and  in  the  lectures  of  the  following  year,  viz.,  1616 
A.D.,  he  first  promulgated  his  views  on  the  circulation  of  the 
blood.  Constant  reference  was  made  to  the  circulation  in  nine 
subsequent  courses  of  lectures ;  but  it  was  not  till  1628  a.d.,  or 
twelve  years  after  he  had  announced  his  startling  discovery  at  the 
College  of  Physicians,  that  his  splendid  work,  called  by  Haller 
Opusculum  Aureum,  saw  the  light.  If  we  assume  that  Harvey 
drew  his  initial  inspiration  from  Fabricius  at  Padua,  he  must  have 
been  engaged  on  his  magnum  opus  for  at  least  a  quarter  of  a 
century. 

Harvey  a  few  years  after  becoming  Lecturer  to  the  College  of 
Physicians,  was  appointed  one  of  the  Physicians  Extraordinary  to 
James  I. 

In  1632  A.D.  he  became  Physician-in-Ordinary  to  Charles  I.,  a 
monarch  who  held  him  in  high  estimation,  and  took  a  keen  interest 
in  his  physiological  discoveries.  Harvey  at  this  date  (1632  a.d.) 
had  a  select  and  very  distinguished  practice,  having  among  his 
patients  Lord  Chancellor  Bacon,  the  celebrated  author  of  the 
Novum  Organum,  and  Thomas  Howard,  the  Earl  of  Arundel,  with 
the  latter  of  whom  he  subsequently  (1636  a.d.)  travelled  as  physi- 
cian in  his  extraordinary  embassy  to  the  Emperor. 

Harvey,  considering  the  ample  fortune  he  left,  must  have  been 
an  eminently  prosperous  man.  He,  however,  profited  nothing  by 
his  anatomical  and  physiological  writings.  On  the  contrary, 
Aubrey  tells  us  he  heard  Harvey  state,  "  that,  after  his  book  on 
the  circulation  of  the  blood  came  out,  he  fell  mightily  in  his 
practice ;  'twas  believed  by  the  vulgar  that  he  was  weak  brained, 
and  all  the  physicians  were  against  him."  ^ 

Harvey  had  a  brilliant  but  chequered  career.  His  position  of 
Court  physician  to  Charles  I.  necessitated  his  sharing  the  fortunes 
of  that  ill-fated  monarch.  He  was  with  Charles  at  the  battle  of 
Edgehill,  and  had  under  his  charge  in  that  engagement  the  Prince 
of  Wales  and  the  Duke  of  York, — a  fact  showing  the  absolute  con- 
fidence the  monarch  reposed  in  him.  Harvey  not  only  took  no 
part  in  the  battle, — he  did  not  even  take  an  interest  in  it.  Aubrey 
informs  us  that  he  took  shelter  with  his  prot^g^s  under  a  hedge 
and  commenced  reading  a  book,  from  which  position  he  was  dis- 
lodged by  the  sudden  appearance  of  a  cannon  ball  in  the  immediate 
vicinity. 

Harvey  was  essentially  a  man  of  peace, — he  was  not  even  a 
politician.  When  his  great  discovery  was  assailed,  it  was  with 
the  utmost  reluctance  he  took  up,  even  in  a  partial  way,  the 
weapons  of  self-defence. 

*  Aubrey,  Lives  of  Eminent  Persons.     2  vols.  8vo.    London,  1813. 


1881).]  PROFESSOR  PETTIGREW'S   HA.RVEIAN   ORATION.  1085 

After  the  battle  of  Edgehill  Harvey  retired  to  Oxford  to  pro- 
secute his  studies  in  "  Generation ;"  and  Aubrey  in  his  quaint  way 
says,  "  I  remember  he  came  several  times  to  our  college  (Trinity) 
to  George  Bathurst,  B.D.,  who  had  a  hen  to  hatch  eggs  in  his 
chamber,  which  they  opened  daily  to  see  the  progress  and  way 
of  generation."  Harvey  was  received  with  open  arms  by  the 
Dons  of  Oxford.  They  conferred  on  him  their  honorary  degree 
of  Doctor  of  Physic ;  and  Oxford  becoming  the  headquarters  of  the 
King  and  the  Eoyal  army,  he  was,  in  1645  A.D.,  made  Warden  of 
Merton  College  in  recognition  of  his  faithful  services  to  the  Eoyal 
cause. 

Oxford  succumbed  to  the  Parliamentary  forces  under  Fairfax 
in  1646  A.D.,  and  at  this  date  Harvey,  in  his  68th  year,  retired 
into  private  life,  and  to  apartments  most  hospitably  provided  for 
him  by  his  brothers  Eliab  and  Daniel,  the  former  of  whom  had 
houses  in  London  (the  City),  at  Roehampton,  and  Eolls  Park, 
Essex, — the  latter  having  houses  at  Lambeth  and  at  Combe, 
near  Croydon. 

In  1651  A.D.  Harvey's  second  great  work,  viz.,  that  On  the 
Generation  of  Animals,  appeared. 

In  1652  A.D.  Harvey  had  attained  the  pinnacle  of  his  greatness, 
and  in  this  year  the  College  of  Physicians  of  London  placed  a 
statue  of  him  in  their  hall.  That  illustrious  body  a  short  time 
after  invited  him  to  become  their  president,  an  honour  which  he 
modestly  'declined.  Harvey,  by  way  of  acknowledgment,  built  at 
his  own  expense  a  handsome  addition  to  the  College  of  Physicians, 
furnished  the  library  with  books,  and  the  museum  with  specimens 
and  surgical  instruments.  He  also  gave  a  grand  banquet,  and 
made  over  to  the  College,  there  and  then,  his  entire  interest  in  the 
new  erection.  Harvey,  though  married  young,  had  no  issue,  and 
subsequently,  in  1656  a.d.,  made  the  College  of  Physicians  the 
heirs  to  his  paternal  estate,  all  which  show  Harvey  to  have  been  a 
large-minded  and  generous  man — a  man  who  gave  freely  not  only 
of  his  time,  but  also  of  his  substance  for  the  public  good. 

Harvey  was  what  is  rare  among  mankind — a  worker  at  first 
hand.  He  dissected  dead  and  living  animals  in  great  numbers, 
and  made  comparative  anatomy  his  stronghold  and  armoury  for 
the  supply  of  facts.  He  also  laid  the  human  subject  under  contri- 
bution whenever  and  wherever  he  had  an  opportunity.  By  attack- 
ing the  circulation  of  the  blood  strongly  from  the  comparative 
anatomy  side,  he  had  the  advantage  of  his  Continental  rivals. 

The  points  which  Harvey  established  by  observation  and  experi- 
ment were  as  follows : — 

L  The  movements  of  the  heart  are  rhythmical,  one  part  of  the 
viscus  resting  while  the  other  is  at  work — the  auricles  contracting 
first  and  then  the  ventricles,  a  brief  pause  intervening. 

II.  The  different  parts  of  the  heart  contract  in  precisely  the 
same  manner  as  the  voluntary  muscles. 


1086  PROFESSOR   PETTIGREW's   HARVEIAN   ORATION.  [jUXE 

III.  The  contraction  or  systole  of  the  ventricles,  and  not  the 
dilatation  or  diastole  of  the  ventricles,  is  the  essential  or  important 
movement  of  the  heart. 

IV.  The  heart  during  the  systole  forces  a  wave  of  blood  through 
and  distends  the  arteries,  and  so  produces  the  pulse,  also  the  spurts 
of  blood  which  proceed  from  wounded  arteries, — the  pulse  and 
the  beat  of  the  heart  being  synchronous  or  very  nearly  so. 

V.  The  arteries  are  thicker,  stronger,  and  more  resilient  than 
the  veins,  because  they  have  to  sustain  the  shock  of  the  contract- 
ing ventricles  during  the  systole. 

VI.  The  auricles  by  their  contraction  forcibly  inject  the  blood 
into  the  ventricles,  the  ventricles  when  they  contract  forcibly 
driving  the  blood  through  the  lungs  and  the  system  gener- 
ally. 

VII.  The  right  auricle  receives  venous  or  dark  blood  from  the 
large  systemic  veins  (venae  cavse — superior  and  inferior),  which  is 
sent  by  the  right  ventricle  through  the  lungs,  and  becomes  arterial 
or  florid  blood ;  the  left  auricle  receives  arterial  or  florid  blood 
from  the  large  veins  of  the  lungs  (pulmonary  veins),  which  the 
left  ventricle  forces  through  all  the  arteries  of  the  body. 

VIII.  The  blood  passes  in  a  ceaseless  stream  and  in  a  circle 
from  the  right  to  the  left  side  of  the  heart  via  the  lungs,  and  from 
the  left  to  the  right  side  of  the  heart  vid  the  arteries  and  veins. 
The  different  movements  of  the  heart  and  the  disposition  and 
arrangement  of  the  cardiac  and  venous  valves  make  this  a 
necessity, 

Harvey  failed  to  demonstrate  how  the  blood  got  from  the 
arteries  to  the  veins,  the  compound  microscope  not  then  being  in 
existence,  and  the  art  of  injecting  bloodvessels  artificially  not 
being  well  understood ;  nevertheless  he  was  led  by  a  sagacious 
induction  to  declare  that  "  the  blood  in  the  animal  hody  is  subjected 
to  a  certain  circular  motion^  that  this  motion  is  incessant,  and  that  the 
pulse  or  contraction  of  the  heart  is  its  sole  efficient  cause."  ^ 

The  manner  in  which  Harvey  established  the  foregoing  proposi- 
tions was  various — sometimes  by  observation,  sometimes  by  ex- 
periment, and  sometimes  by  induction  as  the  product  of  observation 
and  experiment  combined.  Having  opened  the  chest  and  peri- 
cardium of  a  living  animal,  he  observed  the  heart  to  be  alternately 
in  action  and  at  rest,  three  principal  events  occurring  in  this 
connexion : — 

1st,  The  heart  became  erect,  struck  the  chest,  and  gave  a  beat. 

2nd,  It  was  constricted  or  contracted  in  every  direction,  and 
became  shorter  and  narrower. 

3rd,  If  grasped  by  the  hand  it  was  found  to  be  an  exceedingly 
firm  body. 

For  these  and   other  reasons  Harvey  concluded  that  the  in- 

*  Exercitatio  Anatomica  de  Motu  Cordis  et  Sanguinis  in  Animalibus,  cap. 
xiv.,  ad  fin. 


1889.]  PROFESSOR  PETTIGREW'S   HARVEIAN   ORATION.  1087 

voluntary  muscles  of  the  heart  contracted  in  precisely  the  same 
manner  as  the  voluntary  muscles  of  the  body ;  that  the  systole 
and  not  the  diastole  was  the  important  movement  of  the  heart ; 
that  the  ventricles  emptied  themselves  of  blood  during  the  systole, 
the  blood  forcibly  driven  from  the  ventricles  distending  the 
arteries  and  producing  the  pulse — the  pulse  being  synchronous 
with  the  beat  of  the  heart— the  arteries  having  no  inherent  or 
independent  action  of  their  own. 

"If,"  remarks  Harvey,  "a  live  snake  be  laid  open,  the  heart 
will  be  seen  pulsating  for  an  hour  or  more,  contracting  and  pro- 
pelling its  contents,  becoming  of  a  paler  colour  in  the  systole 
when  it  empties  itself,  of  a  deeper  hue  in  the  diastole  when 
it  is  filled.  In  this  animal  the  vena  cava  enters  the  heart  at 
its  lower  part,  and  the  aorta  leaves  it  at  the  upper  part.  Now, 
if  the  vein  be  taken  between  the  finger  and  thumb,  or  seized  by 
the  dissecting  forceps  a  little  way  below  the  heart,  and  the  in- 
coming current  of  blood  be  thereby  arrested,  you  will  see  the  part 
which  intervenes  between  the  obstruction  and  the  heart  fall  empty, 
and  the  heart  itself  becomes  smaller  and  of  a  paler  colour  than  it 
was  before,  beating  more  slowly,  too,  as  if  it  were  about  to  die. 
But  the  impediment  to  the  flow  of  blood  being  removed, 
instantly  the  colour,  the  size,  and  the  motion  of  the  heart  are 
restored. 

"  If,  on  the  contrary,  the  artery  instead  of  the  vein  be  com- 
pressed, the  part  between  the  obstacle  and  the  heart  immediately 
becomes  inordinately  distended,  of  a  deep  purple  or  livid  colour, 
and  at  length  so  much  oppressed  that  it  looks  as  though  it  would 
burst ;  but  on  the  obstruction  being  removed,  everything  returns 
forthwith  to  its  pristine  state.  Here,  therefore,  we  have  evidence 
of  threatened  death  from  two  opposite  causes — extinction  through 
deficiency,  and  suffocation  through  excess." 

The  alternate  opening  and  reception  of  blood  and  closing  and 
discharge  of  blood  by  the  several  compartments  of  the  heart, 
coupled  with  the  disposition  and  action  of  the  cardiac  valves, 
induced  Harvey  to  deal  with  the  quantity  of  blood  moved  on  in 
relays  by  the  different  parts  of  the  heart.  He  concluded  that  the 
quantity  of  blood  passed  through  the  heart  in  a  given  time  was 
greater  than  could  reasonably  be  supplied  by  the  food  and  drink 
in  a  corresponding  time,  and  that  the  blood  must  of  necessity 
move  in  a  circle,  and  be  to  a  large  extent  old  blood,  i.e.,  blood 
already  made  and  existing  in  the  system,  as  contradistinguished 
from  the  young  or  new  blood  added  from  time  to  time  as  the  result 
of  primary  and  secondary  digestion. 

That  the  blood  flows  in  a  circle  as  indicated  was  demon- 
strated on  the  living  subject  by  Harvey  in  a  very  ingenious 
manner  as  regards  the  extremities.  His  words  are : — "  That 
the  blood  enters  a  limb  by  the  arteries  and  returns  from 
it  by  the  veins  is  readily  proved  experimentally.     If  a  ligature 


1088  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [jUNE 

be  thrown  about  the  upper  part  of  an  arm — one  who  is  lean 
and  has  large  veins  being  the  best  subject  for  the  trial — and 
quickly  drawn  as  tightly  as  it  can  be  borne,  it  will  be  found 
that  the  arteries  do  not  pulsate  beyond  the  obstruction,  whilst 
they  throb  violently  and  appear  preternaturally  distended  above  it. 
The  hand  under  these  circumstances  retains  its  natural  appear- 
ance, although  if  the  binder  be  kept  on  even  for  a  minute 
or  two  it  will  begin  to  look  livid  and  to  fall  in  temperature. 

"  But  if  the  bandage  be  now  slackened  a  little — be  brought  to 
the  state  of  medium  tightness  used  in  bloodletting — the  hand  and 
arm  will  immediately  become  suffused,  and  the  superficial  veins 
show  themselves  tumid  and  knotted,  the  pulse  at  the  wrist  in  the 
same  instant  beginning  to  beat  as  it  did  before  the  application  of 
the  bandage. 

"  The  difference  in  the  effect  of  the  tight  and  of  the  medium 
bandage,  therefore,  is  this : — The  tight  bandage  not  only  obstructs 
the  veins,  but  the  arteries  also,  whereby  it  comes  to  pass  that  the 
blood  neither  comes  nor  goes  in  the  member. 

"The  medium  bandage,  again,  obstructs  the  veins,  the  more 
superficial  among  them  especially,  whilst  the  arteries  lying  deeper, 
being  firmer  in  their  coats  and  forcibly  injected  by  the  heart, 
are  not  obstructed,  but  continue  conveying  blood  to  the  limb, 
whence  follows  the  unusual  fulness  of  the  veins,  and  the 
necessary  inference  that  the  blood  flows  incessantly  outwards 
from  the  heart  by  the  arteries,  and  ceaselessly  returns  to  it  by 
the  veins." 

In  Harvey's  mind  there  was  no  dubiety  as  to  the  structure, 
movements,  and  function  of  the  heart,  or  the  structure  and  func- 
tion of  the  arteries  and  veins.  An  artery  had  thick  walls,  and 
was  strong  and  resilient,  not  to  prevent  the  escape  of  the  subtle, 
hypothetical  vital  spirit  generally  believed  in,  but  to  sustain  and 
distribute  the  stroke  or  shock  of  the  heart  during  the  systole. 
The  veins  had  thin  walls  and  were  non-resilient,  because  they 
were  passive  and  were  not  called  upon  to  sustain  any  great  degree 
of  pressure.  The  veins  differed  from  the  arteries  in  being  furnished 
throughout  their  course  with  valves.  This  fact  had  significance 
for  Harvey.  The  chief  duty  of  the  venous  valves,  according  to 
him,  was  to  prevent  the  venous  blood  flowing  from  venous  trunks 
to  venous  branches, — in  other  words,  to  prevent  regurgitation  or 
retrogression. 

"  This  truth,"  he  remarks,  "  is  readily  demonstrated  in  the  arm 
bound  as  for  bloodletting.  The  veins  are  then  seen  turgid,  and 
with  knots  or  swellings  at  intervals  in  their  course,  at  the  points 
especially  where  one  branch  joins  another.  The  knots  in  question 
mark  the  positions  of  the  valves, — a  fact  which  is  immediately 
made  manifest  if  an  attempt  be  made  to  force  the  blood  in  one 
of  the  vessels  from  above  downwards  by  the  pressure  of  a  finger. 
The  valve  nearest  the  part  below  the  point  of  pressure  starts  at 


1889.]  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  1089 

once  into  action,  and  can  be  felt  distinctly  as  a  hard,  resistant 
knot. 

"  If  the  pressure  be  now  reversed,  the  vein  being  compressed 
by  the  point  of  a  finger  beyond  a  valve,  the  blood  within  it  will 
then  be  easily  streaked  upwards  until  it  passes  the  valve  above, 
when  the  part  of  its  canal  between  this  and  the  point  of  pressure 
will  not  only  be  emptied,  but  so  remain  so  long  as  the  pressure 
is  continued. 

"  The  pressure  below  being  now  withdrawn,  the  empty  vein  fills 
instantly  and  looks  turgid  as  before.  The  valves  of  the  veins, 
consequently,  act  not  otherwise  than  do  the  sigmoid  valves  at  the 
roots  of  the  aorta  and  pulmonic  artery,  and  as  the  mitral  and  tri- 
cuspid valves  between  the  ventricles  and  auricles  of  the  heart. 
They  offer  no  impediment  to  the  flow  of  the  blood  in  the  direction 
of  their  trunks,  but  oppose  effectual  barriers  to  its  course  towards 
their  branches." 

Prior  to  the  days  of  Harvey,  the  diastole,  and  not  the  systole,  was 
regarded  as  the  e-ssential  or  important  movement  of  the  heart. 
The  venous  valves,  moreover,  were  regarded  as  obstructions  to 
retard  the  progress  of  the  blood  in  the  veins,  the  venous  blood 
being  then  supposed  to  feed  the  tissues.  All  this  was  changed,  as 
if  by  magic,  by  Harvey.  He  showed  that  the  systole,  and  not  the 
diastole,  was  the  efficient  or  essential  movement  of  the  heart ;  that 
the  arterial  and  not  the  venous  blood  fed  the  tissues  ;  further,  that 
the  blood  flowed  in  a  circle  not  only  through  the  lungs,  but  also 
through  the  whole  body. 

"  In  this  way  it  is,"  says  he,  "  that  all  parts  of  the  body  are 
nourished,  cherished,  and  quickened  by  the  warm,  spirituous,  more 
perfect,  and  truly  alimentive  blood ;  which  then,  cooled  by  contact 
with  the  parts,  and  become  effete,  returns  to  its  sovereign,  the  heart, 
as  its  source,  then  to  recover  its  pristine  state  of  excellence,  to 
receive  a  fresh  infusion  of  native  heat,  to  be  impregnated  anew 
with  spirits,  again  to  go  forth  replete  with  life-giving  power,  and 
all  this  accomplished  by  the  action  of  the  heart  alone." 

Here  was,  indeed,  a  revelation  of  the  first  magnitude.  Physiology 
was  henceforth  to  be  provided  with  a  new  platform,  and  that 
platform  was  placed  so  high,  that  it  was  literally  in  the  clouds  as 
compared  with  any  similar  structure  reared  before  the  advent  of 
Harvey.  It  were  an  easy  task  to  trace  nearly  all  the  important 
modern  physiological  discoveries,  directly  or  indirectly,  to  the 
primal  or  central  discovery  of  the  circulation  of  the  blood  by 
Harvey,  but  every  one  is  familiar  with  the  progress  of  events,  as 
recorded  in  the  numerous,  admirably  illustrated,  modern,  phy- 
siological text-books,  published  since  Harvey's  masterpiece  saw  the 
light. 

It  only  remains  for  me  to  state  in  conclusion,  that  the  history  of 
the  discovery  of  the  circulation  of  the  blood  is  at  once  deeply 
interesting  and  instructive.     At  first  the  new  doctrine  was  doubted 

EDINBUKQH    MED.    JOURN.,   VOL.    XXXIV. — NO.   XII.  6  Y 


1090  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  [jUNE 

and  disbelieved,  and  attempts  made  to  refute  it;  then  it  was  slowly 
accepted,  but  little  or  no  credit  given  to  the  discoverer:  as  the 
grand  generalization  became  more  and  more  popular,  detractors 
endeavoured  to  show  that  the  circulation  of  the  blood  was  known 
to  the  ancients  and  certain  of  the  moderns.  Ultimately  several 
nationalities,  suddenly  realizing  the  magnitude  and  importance  of 
the  discovery,  unblushingly  endeavoured  to  appropriate  it,  without 
a  tittle  of  evidence  to  support  their  preposterous  and  wholly 
indefensible  claims. 

I  have  taken  pains  in  the  foregoing  pages  to  epitomize  all  that 
had  been  done  to  the  circulation  prior  to  the  advent  of  Harvey, 
and  if  I  have  at  all  succeeded  in  stating  the  case,  it  will  be  abund- 
antly evident  that,  with  the  exception  of  the  pulmonic  circulation 
discovered  by  Servetus,  the  true  nature  of  the  circulation,  as  a 
whole,  was  absolutely  unknown  until  Harvey  laboured  and  wrote. 
It  is  necessary  to  state  this  distinctly  and  emphatically — the 
Italians  and  others  having  no  facts  whatever  at  their  disposal, 
either  to  excuse  or  justify  them  in  their  persistent  attempts  to 
deprive  Harvey  of  his  well-merited  honour. 

Harvey's  training,  habits,  opportunities,  and  natural  bias,  all 
fitted  him  for  making  the  great  discovery ;  of  a  studious,  gentle 
disposition,  sagacious,  patient,  and  persevering  beyond  most  men, 
he  devoted  his  leisure  hours,  whether  engaged  in  private  practice, 
the  hospital,  the  court,  or  the  camp,  to  the  solution  of  the  mysterious 
and  all  important  problem.  The  needle  is  not  more  true  to  the 
pole  than  he  was  to  the  cardinal  idea  of  his  life.  He  worked  at  it 
in  season  and  out  of  season,  day  and  night  as  it  were,  for  a 
quarter  of  a  century  or  more.  He  verified  in  his  labours  and  life 
Shakespeare's  sublime  lines : — 

*'  To  thine  own  self  be  true  ; 
And  it  must  follow,  as  the  night  the  day, 
Thou  canst  not  then  be  false  to  any  man." 

Harvey  has  been  blamed,  among  other  things,  for  not  quoting 
authorities ;  there  were — Servetus  excepted — none  to  quote.  He 
began  de  novo  as  it  were,  and,  by  ceaseless  thinking  and  indefatig- 
able work  and  experiment,  he  accumulated  facts,  at  first  laboriously 
and  slowly,  latterly  with  less  effort,  comparatively  quickly,  and  of 
a  more  and  more  important  character.  These  facts  he  arranged 
in  the  most  severely  logical  order,  and  each  one  was  made  to 
contribute  its  quota  to  the  grand  generalization.  Nothing  was 
taken  for  granted.  Each  step  in  the  discovery  must  be  argued 
and  demonstrated.  If  proof  is  required  that  the  auricles  forcibly 
inject  the  blood  into  the  ventricles,  the  apices  of  the  ventricles  are 
removed  in  the  living  animal,  and  the  blood  seen  to  squirt  from 
the  injured  living  organ  every  time  the  auricles  contract.  By 
gentle,  almost  insensible  gradations  he  led  up  to  his  great 
discovery,  and  all  who  listened,  read,  or  examined,  were  sooner  or 
later  convinced. 


1889.]  PROFESSOR   PETTIGREW'S   HARVEIAN   ORATION.  1091 

Had  Harvey's  friend  and  patient,  Bacon,  the  illustrious  author 
of  the  Novum  Organum,  sought  for  a  confirmation  of  his  inductive 
method  of  reasoning,  he  could  not,  had  he  searched  all  the  world 
over,  have  got  a  better  one  than  was  afforded  by  the  discovery  of 
the  circulation  of  the  blood.  Albeit  the  said  discovery  was, 
strange  to  relate,  made  a  few  years  before  the  Novum  Organum 
was  published.^ 

Harvey's  methods  were  all  very  simple,  but  there  was  a  reality 
and  a  thoroughness  about  them  which  was  very  striking.  His  few 
instruments,  small  note  books,  sparse  diagrams,  and  even  his 
ingenious  and  well-contrived  experiments,  present  no  very  formid- 
able array,  but  behind  all  was  his  placid,  powerful  intellect 
driving  home  noiselessly,  as  with  a  hydraulic  press,  his  mighty 
inductive  wedge,  which  insinuated  itself  between  the  contending 
views  of  his  predecessors,  and  split  and  drove  them  apart,  so  as 
quietly  but  surely  to  take  possession  of  the  hard  won  field,  never 
to  be  dislodged  while  history  and  medical  science  exist. 


11. —NOTE  ON  SAEXINGER'S  AND  WINTER'S  SECTIONS. 

By  A.  H.  F.  Barbour,  M.D.,  F.R.C.P.E.,  Lecturer  on  Midwifery  and 
Diseases  of  Women  in  the  School  of  Medicine,  Edinburgh,  etc. 

{Read  before  the  Obstetrical  Society  of  Edinburgh,  9th  January  1889.) 

Professor  Saexinger  of  Tubingen  published  in  June  last  a 
frozen  section  of  a  case  that  died  during  the  first  stage  of  labour. 
The  subject,  18  years  of  age,  was  admitted  to  the  Maternity  in 
December  1887.  She  was  suffering  from  phlegmonous  inflamma- 
tion of  the  right  breast.  The  uterus  was  four  fingerbreadths  above 
the  umbilicus,  the  child  being  alive  and  in  the  first  position.  The 
external  conjugate  measured  7|  in.  (18'5  cm.)  She  died  from 
sepsis  eleven  days  after  admission,  about  a  month  before  her  con- 
finement was  due.  Labour  pains  were  present  a  few  hours  before 
death,  and  it  was  then  noted  that  the  finger  passed  through  both 
external  and  internal  os,  and  that  the  head  was  low  and  in  the 
first  position. 

In  the  beautiful  drawings  of  this  section  in  Dr  Saexinger's  Atlas 
the  following  points  are  of  special  interest.^ 

The  length  of  the  lower  uterine  segment  and  the  position  of  the 
bladder  are  noteworthy.  The  reflection  of  the  utero-vesical  peri- 
toneum is  ^  in.  (1-2  cm.)  above  the  pubes;  and,  extending  from  os 

1  The  Novum  Organum  appeared  in  1620  a.d.  Although  Harvey's  work  did 
not  come  out  till  1628  a.d.,  he  had  announced  his  views  as  early  as  1616, 
and  there  is  reason  to  believe  that  his  Disquisition  on  the  Motion  of  the 
Heart  and  Blood  in  Animals  was  actually  written  before  1619  a.d. 

2  The  plates  of  the  Atlas  were  placed  before  the  Fellows  ;  and  the  vertical 
mesial  section  is  reproduced  in  my  Atlas  of  the  Anatomy  of  Labour,  Student's 
Edition,  pi.  xii. 


1092  DR   A.   H.   F.   BARBOUR'S   NOTE   ON  [jUNE 

externum  to  this  point/  we  have  3f  in.  (9*4  cm.)^  in  which  the 
wall  is  only  about  half  the  thickness  of  what  it  is  throughout  the 
rest  of  the  anterior  wall  and  fundus  ("2  cm.  instead  of  "4  cm.) 

The  bladder  extends  from  2 '4  in.  (6  cm.)  below  the  upper  edge 
of  the  symphysis  to  1'8  in.  (4'5  cm.)  above  the  same.  Its  walls 
are  in  apposition  behind  the  symphysis — except  the  lowest  part ; 
above  the  symphysis  they  are  separated  by  urine  to  the  extent  of 
*6  in.  (1'5  cm.). 

"We  see  in  this  section,  therefore,  these  two  remarkable  features : 
reflection  of  the  peritoneum  ^  in.  above  the  brim,  and  also  the 
highest  point  of  the  but  moderately  distended  bladder  1"8  in.  above 
the  brim — and  both  conditions  present  in  a  patient  who  has  been 
only  a  few  hours  in  labour,  or  in  labour  only  long  enough  to  dilate 
the  cervix  till  it  admit  one  finger. 

Dr  Berry  Hart's  valuable  inquiry  into  the  position  of  the  bladder 
in  labour  has  shown  that  during  the  second  stage  we  have  the 
bladder  becoming  in  part  an  abdominal  organ.  From  the  expression 
he  uses  it  might  be  supposed  that  he  meant  that  the  bladder  was 
lifted  up  so  as  to  become  in  toto  an  abdominal  organ ;  but  all  that  he 
says  is,  that  the  bladder  is  above  the  pubes.  Braune's  section  (on 
which  Dr  Hart  based  his  observation)  always  puzzled  me,  for  the 
small  fragment  (the  size  of  the  finger-nail)  seen  above  the  pubes 
could  never  represent  the  whole  bladder.  I  took  it  to  be  the  corner  of 
the  organ  perhaps  displaced  to  the  right  so  as  to  be  cut  through  only 
in  part,  till  I  came  to  read  carefully  Braune's  text,  which  at  once 
made  the  matter  clear.  For  he  says,  "  Tiie  bladder  was  completely 
empty  and  pressed  flat.  Behind  the  symphysis  its  walls  were  so 
thin  that  they  could  scarcely  be  recognised.  Above  and  helow  the 
symphysis,  where  the  pressure  has  not  affected  it  so  much,  it  is 
broader  and  more  easily  seen." 

The  study  of  Schroeder's  section  and  my  own  led  me  to  believe 
that  this  dra wing-up  of  the  bladder  could  not  take  place  till  the 
second  stage,  for  in  both  the  bladder  is  just  as  low  down  as  in 
pregnancy.  But  here  we  have  a  bladder  already  in  the  first  stage 
a  partially  abdominal  organ ;  and  it  is  not  the  mere  accumulation 
of  urine  which  has  raised  the  fundus,  for  the  utero-vesical 
peritoneum  is  above  the  brim. 

Associated  with  this  relation  of  the  bladder  we  have  an  unusually 
long  and  well-marked  lower  uterine  segment.  It  is  possible  that 
these  conditions  may  be  the  result  of  a  peculiarity  in  the  growth 
of  the  uterus  during  pregnancy ;  but  I  think  we  have  a  more 

1  It  is  unfortunate  that  Saexinger  does  not  record  any  microscopic  examina- 
tion of  the  cervix  and  lower  segment ;  nor  can  I  understand  why  he  places  the 
OS  internum  where  he  marks  it  on  his  figure,  for  this  makes  a  remarkably 
short  cervical  canal.  By  the  time  that  the  os  externum  is  sufficiently  dilated 
to  admit  the  finger,  the  position  of  the  os  internum  would  surely  be  higher  up. 

2  This  does  not  represent  the  total  length  of  the  lower  uterine  segment, 
which  extends  to  the  line  of  firm  attachment  of  the  peritoneum,  the  latter  not 
being  shown  in  a  frozen  section. 


1889.]  SAEXINGER's   AND   WINTER'S   SECTIONS.  1093 

satisfactory  explanation  in  an  unusual  elongation  of  the  lower 
segment  during  the  first  stage  of  labour,  favoured,  perhaps,  by  the 
contracted  condition  of  the  pelvis.  We  must  wait,  however,  for 
other  sections  of  the  first  stage  to  settle  this  matter. 

Other  points  of  interest  in  this  section  are  that  the  placenta, 
which  is  divided  mesially,  occupies  rather  less  than  one-third  of 
the  vertical  circumference  of  the  uterus,  and  averages  f  in.  (1"9  cm.) 
thick.  Further,  that  the  posterior  vaginal  wall  is  in  its  upper  part 
remarkably  thin — about  one-half  of  the  thickness  of  the  anterior  at 
corresponding  level.  And,  finally,  that  with  an  external  conjugate 
of  about  7|  in.  during  life,  we  have  a  true  conjugate  of  only  312  in. 

Still  more  recently  than  Saexinger's  there  have  been  published 
two  other  sections^  from  the  first  stage  by  Dr  Winter,  Privat- 
docent  of  Midwifery  and  Assistant  in  the  University  Gynecological 
Clinique  at  Berlin.  They  are  both  from  cases  of  eclampsia,  the 
one  a  ii.-para  at  full  time,  and  the  other  a  i.-para  at  the  eighth 
month.  In  both,  pains  were  present  some  hours  before  death — the 
patient  being  under  observation  for  seventeen  hours  in  the  first 
case,  and  twenty-four  hours  in  the  second.  In  the  first  case  the 
cervix  admitted  the  finger  below,  but  was  closed  above,  and 
in  the  second  allowed  it  to  pass  easily  through  the  whole 
canal.  The  special  interest  in  these  two  cases  centres  in  the 
placenta ;  and  it  is  a  curious  fact  that  Winter  in  his  two  sections 
should  have  fallen  upon  illustrations  of  the  two  important  patho- 
logical conditions  of  that  organ,  viz.,  placenta  prsevia  and 
accidental  haemorrhage. 

In  the  placenta-praevia  section  the  placenta  comes  down  to 
within  four-fifths  of  an  inch  of  the  os  internum,  but  is  not 
detached,  nor  was  there  bleeding  from  the  cervix.  The  membranes 
are  separated  anteriorly  for  a  little  more  than  ^  in.,  i.e.,  not  quite 
up  to  the  lower  edge  of  the  placenta.  The  striking  feature  in  the 
placenta  is  the  way  in  which  it  has  been  flattened  by  the  child's 
head  below  the  brim  and  indented  by  its  limbs  above  it.  Winter 
draws  attention  especially  to  the  former  point,  and  gives  the 
results  of  his  microscopic  examination,  which  is  so  interesting  that 
I  quote  it  in  full : — "  In  the  bulky  upper  part  of  the  placenta  the 
tissue  is  laxer.  The  chorionic  villi  lie  widely  separated  from  each 
other,  so  that  between  them  there  is,  here  and  there,  a  wide  inter- 
villous space.  Between  the  villi  there  is  in  many  places  a  great 
quantity  of  blood,  and  the  bloodvessels  are  mostly  distended  with 

blood The  decidua  serotina  shows  a  distinct  opening-out  of 

its  deeper  layers,  uniting  it  with  the  uterine  muscle,  and  gives  appear- 
ances such  as  Kuge  has  described  as  the  result  of  the  first  uterine 
contractions  in  labour.  In  the  part  of  the  placenta  in  the  pelvis, 
the  chorionic  villi  lie  very  close — are  thickset — and  interlocked, 
so  that  one  can  scarcely  speak  of  an  intervillous  space.     Between 

^  Reproduced  in  my  Atlas  of  the  Anatomy  of  Labour,  Student's  Edition, 
pi.  xii. 


1094  DR  A.  H.  F.  Barbour's  note  on  [june 

the  villi  there  is  nowhere  blood,  the  vessels  of  this  part  being  com- 
pletely empty.  The  decidua  serotina  shows  here  no  opening-out 
of  its  deeper  layers,  and  its  limit  runs  almost  in  a  straight  line." 

On  this  he  bases  the  statement  that  the  child  may  interfere 
with  its  own  circulation  to  such  a  degree  as  materially  to  affect  the 
aeration  of  its  blood,  although  scarcely  to  a  fatal  extent.  I  do  not 
think  that  he  here  makes  sufficient  allowance  for  post-mortem 
changes.  When  Waldezer  spoke  of  the  uterus  as  moulding  itself  on 
the  intervertebral  discs  we  thought  that  he  was  riding  the  plasticity 
of  the  uterus  a  little  too  hard,  and  the  same  must  be  said  of  the 
moulding  of  the  placenta  by  the  foetus  here.  It  is,  however,  a 
remarkable  fact  that  the  placenta  is  so  very  much  thinner  here  in 
its  lower  third,  although  the  liquor  amnii  is  still  in  the  uterus. 
That  the  placenta  is  not  yet  separated  over  the  lower  segment  is 
also  noteworthy,  which  must  be  taken  along  with  the  fact  that 
the  first  stage  is  only  beginning. 

As  to  the  changes  immediately  concerned  with  the  first  stage, 
we  have  a  lower  uterine  segment  one-half  the  thickness  of  the 
wall  above.  We  have  no  data  for  determining  the  firm  attach- 
ment of  the  peritoneum  in  a  frozen  section,  and  the  thin  portion 
will  appear  to  be  longer  in  this  case,  because  the  uterine  wall  is 
generally  thinner  at  the  placental  site.  The  membranes  are 
separated  for  rather  more  than  half  an  inch  (1*4  cm.)  in  front  and 
twice  that  distance  (3  cm.)  behind.  Further,  the  lips  of  the 
cervix  are  being  taken  up  unequally,  the  posterior  being  more 
shortened  and  thinned  than  the  anterior. 

Turning  now  to  the  case  of  accidental  haemorrhage,  we  notice  that 
while  blood-stained  mucus  came  from  the  cervix,  there  was  no 
bleeding  to  speak  of.  The  section  was  made  of  the  uterus  and 
pelvis  removed  from  the  body,  and  only  a  plate  of  the  uterine 
cavity  with  placenta  and  membranes  is  given.  The  placenta  has 
been  separated  from  the  uterine  wall  by  a  large  haematoma,  and  is 
detached  over  one-half  of  its  site,  the  clot  being  2*2  in.  long  and 
1'6  in.  thick,  and  having  at  one  point  broken  through  the  placental 
tissue  so  as  nearly  to  reach  the  foetal  surface.  At  the  right  margin 
it  extends  to  the  edge  of  the  placenta,  from  which  a  thin  layer  of 
bloody  serum  spreads  underneath  the  membranes  downwards,  dis- 
secting the  membranes  off  in  the  middle  line  for  2*4  in.  This 
section,  therefore,  is  of  the  first  importance  as  giving  us  an 
anatomical  basis  for  accidental  haemorrhage.  With  regard  to  the 
facts  immediately  concerned  with  the  first  stage,  we  have  a  lower 
uterine  segment  2*4  in.  long  ^  and  one- third  the  thickness  of  the 
wall  above.  Further,  the  membranes  are  separated  anteriorly  for 
1-8  in.  and  posteriorly  for  '4  in.  Finally,  the  posterior  lip  is  more 
taken  up  and  thinner  than  the  anterior. 

^  This  distance  from  the  os  internum  represents  the  reflection  of  the  peri- 
toneum in  the  plate,  and  is  alao  the  distance  of  the  firm  attachment  according 
to  Winter. 


1889.]  SAEXINGER'S   AND   WINTER'S   SECTIONS.  1095 

Putting  the  facts  in  these  two  sections  together,  we  find  that 
with  a  further  advance  in  the  first  stage  in  the  second  preparation 
(as  indicated  by  the  greater  degree  of  dilatation  of  the  cervix 
before  death)  we  have  a  higher  position  of  the  utero- vesical  peri- 
toneum, with  a  greater  tliinning  of  the  wall  below  it  and  a  more 
extensive  separation  of  the  membranes.  These  sections,  therefore, 
as  well  as  that  of  Saexinger,  bear  out  what  I  drew  attention  to  in 
my  own  sections  of  the  first  stage,  that  the  uterine  pains  during 
this  stage  are  expended  in  thinning  the  lower  segment  of  the 
uterus  as  well  as  in  dilating  the  cervix ;  while  Saexinger's  shows 
in  addition  that  this  elongation  of  the  lower  segment  may  be 
accompanied  with  upward  displacement  of  the  bladder.  It  is 
noteworthy  that  in  Winter's  sections  as  in  Schroeder's  the  posterior 
lip  is  being  taken  up  more  rapidly  than  the  anterior.  Schroeder 
considered  this  exceptional,  while  Winter  would  regard  it  as  a 
normal  occurrence.  We  must  wait,  however,  for  more  sections  to 
settle  this  point. 


Ill— THE  NATURE  AND  AIM  OF  INVESTIGATIONS  ON 
THE  STRUCTURAL  ANATOMY  OF  THE  FEMALE  PELVIC 
FLOOR. 

By  D.  Berry  Hart,  M.D.,  F.R.C.P.E.,  F.R.S.E.,  Lecturer  on  Midwifery, 
Surgeons'  Hall,  Edinburgh,  etc. 

{Read  before  the  Edinburgh  Obstetrical  Society,  9th  Janwiry  1889.) 

For  some  years  past  I  have  published  various  communications 
on  what  I  termed  the  structural  anatomy  of  the  female  pelvic  floor. 
To-night  I  wish  to  define  the  scope  of  these  researches,  to  consider 
some  criticisms  advanced  by  others,  and  to  indicate  whether  or  not 
the  opinions  advanced  have  been  modified  by  fresh  facts. 

This  subject  will  best  be  considered  under  the  following  heads : — 

I.  The  Aim  of  Structural  Anatomy. 

II.  The  Methods  of  Investigation  necessary. 

III.  The  Besult  attained  hy  it. 

I.  The  Aim  of  Structural  Anatomy. — This  necessitates,  in  the  first 
place,  a  definition  of  what  we  mean  by  the  term  "  Pelvic  Floor." 
As  the  structural  anatomy  has  its  special  bearing  on  the  functions 
of  the  pelvic  floor,  it  is  to  be  defined  so  as  to  satisfy  clinical  and 
not  dissectional  requirements.  The  abdominal  canity  has  its 
inner  aspect  defined  by  peritoneum,  and  therefore  I  would  define 
the  upper  aspect  of  the  clinical  pelvic  floor  by  the  peritoneum 
covering  it,  the  uterus  and  appendages  being  removed  of  course. 
For  similar  clinical  reasons  the  skin  of  the  genitals  and  parts 
adjacent  define  its  outer  aspect.  This  gives  the  pelvic  floor  the 
obstetrician  has  to  deal  with. 

The  aim  of  structural  anatomy  is  to  study  the  mechanism  of 


1096  DR  D.  BERRY  HART  ON  THE  [jUNE 

this  pelvic  floor,  so  as  to  understand  the  changes  taking  place  in 
it  during  labour  and  the  alterations  brought  about  in  it  by  excessive 
intra-abdominal  pressure.  Its  main  object  is,  therefore,  to  study 
the  mechanism  of  parturition  and  prolapus  uteri,  although  the  func- 
tions of  the  bladder  and  rectum  also  come  up  for  consideration. 

II.  The  Methods  of  Investigation  necessary. — In  no  subject  is  it 
more  necessary  to  have  definite  ideas  as  to  methods.  Inasmuch  as 
structural  anatomy  is  the  anatomy  of  living  function,  the  relation 
of  parts  must  be  studied  in  the  simplest  manner  possible.  Thus 
I  have  always  used  the  following  methods,  A  fresh  pelvis  is 
frozen  and  sawn  in  definite  directions.  The  direction  of  a  section, 
so  far  as  the  structure  of  the  pelvic  floor  is  concerned,  is  of  impor- 
tance. The  main  directions  must  be  sagittal  mesial,  sagittal  lateral, 
and  axial  coronal.  The  most  important  are  the  axial  coronal, 
inasmuch  as  intra-abdominal  pressure  acts  in  the  axis  of  the  pelvic 
inlet,  and  as  the  vagina  and  urethra  are  at  right  angles  to  it  we  get 
the  proper  thickness  of  tissue.  Any  obliquity  of  the  section  to  tlie 
pelvic  axis  leads  to  error  in  estimating  the  relative  thicknesses. 

When  the  sections  are  made  and  drawn,  the  next  thing  is  the 
examination.  This  must  be  limited  to  mere  fingering,  so  that  the 
lines  of  loose  tissue  may  be  recognised.  It  is  often  helpful  to 
place  the  sections  under  a  water-tap,  so  as  to  render  these  lines 
more  evident.  In  doubtful  points  microscopic  examinations  should 
be  made.  The  ordinary  dissectional  method  is  to  be  avoided,  as  loose 
tissue  is  cut  away,  the  relations  disturbed,  and  lines  of  cleavage 
artifically  made.     Of  course  dissection  has  its  uses  afterwards. 

III.  The  Results  attained  hy  it. — In  the  female  pelvic  floor  I 
described,  in  sagittal  mesial  section,  a  division  into  pubic  and 
sacral  segments,  the  line  of  junction  being  the  vagina.  The  pubic 
segment  was  described  as  mobile,  and  made  up  of  loose  tissue, 
thus  being  in  direct  contrast  to  the  firm  sacral  segment.  The 
mobility  of  the  pubic  segment  is  due  chiefly  to  its  loose  attach- 
ment to  the  pubis,  where  the  retro-pubic  fat  lies.  This  mobility 
is  so  marked  that  we  get  the  pubic  segment  displaced,  even  in  the 
genu-pectoral  posture ;  more  markedly  displaced  during  labour, 
when  it  is  in  part  drawn  up ;  and  most  markedly  of  all  in  pro- 
lapsus uteri. 

The  important  displacement  is  the  second  one.  I  first  drew 
attention  to  it  in  Braune's  section,  and  since  then  it  has  been  found 
well  marked  in  others,  viz.,  Chiara's,  Chiari's,  Saexinger's.  In  those 
of  Schroeder  and  Barbour  the  labour  was  too  slightly  advanced  for 
its  production.  Clinically  it  is  easily  recognised,  and  has  been 
confirmed  by  Croom,  Barbour,  and  many  others.  In  Braune's 
section  it  was  associated  with  marked  thickening  of  the  anterior 
uterine  wall,  probably  because  the  woman  died  during  a  pain. 
In  none  other  is  the  thickening  shown,  but  this  agrees  with  the 
facts  as  to  the  bladder  brought  out  by  me  ;  in  some  the  bladder  is 
relaxed,  in  others  contracted. 


1889.]  ANATOMY   OF   THE   FEMALE   PELVIC   FLOOR.  1097 

In  considering  the  changes  in  the  pelvic  floor  segments  pro- 
duced by  the  birth  of  the  child  at  full  time,  I  stated  in  1880  that 
the  pubic  segment  was  drawn  up  "partly  above  the  brim"  (p.  15, 
Structural  Anatomy,  1880),  that  this  drawing  up  was  "  chiefly  in 
the  middle  line"  (p.  16,  ibid.),  and  also  that  the  bladder  was 
above  the  symphysis,  even  in  the  first  stage  of  labour.  From  the 
statement  in  one  of  my  papers,  that  "  only  the  part  of  the  bladder 
above  the  pubis  is  available  for  the  reception  of  urine,"  it  will  be 
seen  that  I  believed  that  the  entire  bladder  might  not  be  ab- 
dominal. These  results  were  based  on  an  examination  of  Braune's 
sagittal  mesial  section  of  a  woman  who  died  at  the  end  of 
pregnancy,  another  where  the  labour  had  advanced  to  the  end  of 
the  first  stage,  and  also  on  Chiara's  figure  of  a  case  of  death  during 
spontaneous  evolution  of  the  foetus.  Since  that  time  several 
sections,  both  of  pregnant  and  parturient  women,  have  been 
issued,  and  we  have,  in  addition,  more  sections  of  the  pelvis  of  the 
non-gravid.  There  is  thus  abundance  of  fresh  material  for  con- 
sidering the  whole  question  once  more,  and  testing  whether  the 
statements  made  in  my  thesis  are  still  borne  out.  To  settle  this 
question  anatomically  we  have  to  consider — 

A.  The  relation  of  the  vagina  to  the  conjugate  in  the  non-gravid 
and  gravid  woman. 

B.  The  relation  of  the  os  internum  uteri  and  lower  uterine  segment 
to  the  conjugate  in  the  gravid  and  parturient  woman. 

C.  The  action  of  the  retracting  uterine  muscle  on  the  pelvic  floor 
segments. 

A.  The  relation  of  the  vagina  to  the  conjugate  in  the  non-gravid 
and  gravid  ivoman. — The  vaginal  axis  in  sagittal  mesial  section  is 
the  most  convenient  topographical  line  to  select,  as  it  is  always 
cut  on  section,  is  the  boundary  line  of  the  pubic  and  sacral 
segments,  and  has  a  perfectly  definite  relation  to  the  conjugate. 
In  the  non-gravid  pelvis  it  will  be  found  that  the  vaginal  slit  in 
sagittal  mesial  section  lies  parallel  to  the  conjugate  and  2|-3  inches 
below  it.  This  distance  is  easily  determined  by  joining  the  con- 
jugate and  vaginal  parallels  by  perpendiculars.  In  the  sections  of 
gravid  women  at  full  time  (Braune's,  Winter's)  the  same  facts  hold 
good,  except  that  the  vagina  lies  on  an  average  of  3  to  4  inches 
below  the  conjugate. 

The  important  fact  now  to  be  noted  is  that  in  a  parturient 
section  the  vaginal  axis  of  the  end  of  pregnancy  can  be  approxi- 
mately determined  by  drawing  a  parallel  to  the  conjugate  3|  inches 
below  it.  This  enables  one  to  see  the  changes  in  the  segments 
induced  by  labour. 

B.  The  relation  of  the  os  internum  uteri  and  lower  uterine  segment 
to  the  conjugate  in  the  gravid  and  parturient  woman. — In  the 
sections  of  Braune,  Waldeyer,  and  Winter,  the  os  internum  is 
below  the  conjugate.  This  is  best  seen  in  Waldeyer's  section,  where, 
however,  a  fracture  of  the  pelvis  has  elevated  the  parts  somewhat.    If 

EDINBURGH   MED.    JOURN.,   VOL.    XXXIV. — NO.    XII.  6   Z 


1098  DR  D.  BERRY  HART  ON  THE  [jUNE 

we  take  the  length  of  the  lower  uterine  segment  as  2  inches,  we 
find  further  that  the  upper  boundary  of  the  lower  uterine  segment 
is  also  below  the  conjugate.  It  may  therefore  be  broadly  stated 
that  at  the  end  of  pregnancy  the  lower  uterine  segment,  os 
internum,  cervical  canal,  and  pubic  segment  are  pelvic,  i.e.,  there 
is  no  projection  of  these  above  the  conjugate. 

If,  now,  we  take  the  parturient  sections  of  Braune,  Chiari, 
Chiara,  and  draw  on  them  the  approximate  vaginal  axis  at  the  end 
of  the  pregnancy,  we  find  that  the  pubic  segment  is  above  its  level, 
the  sacral  segment  below.  This  is  marked  in  Braune's  section, 
more  marked  in  Chiari's,  and  most  of  all  in  Chiara's. 

But  a  further  point  to  be  noted  is  as  follows.  The  upper 
boundary  of  the  distended  lower  uterine  segment  is  the  retraction 
ring,  otherwise  known  as  contraction  ring.  If  we  look  at  the 
canalized  lower  uterine  segment  and  cervix  in  the  three  parturient 
sections  already  quoted,  we  find  the  ring  at  the  level  of  the 
promontory  behind,  but  2  inches  above  the  symphysis  in  front. 
The  vertical  diameter  between  retraction  ring  and  os  externum  is 
the  same  behind  as  in  front,  so  that  it  is  evident  the  higher 
portion  in  front  is  due  to  the  higher  position  of  the  pubic  segment. 
This  displacement  is  given  in  detail  in  Braune's  section,  where  we 
find  bladder,  peritoneum,  and  retro-pubic  fat  all  higher.  Braune's 
drawing  is  so  accurate  that  there  can  be  no  doubt  to  any  eye 
accustomed  to  such  work ;  while  Chiari's  section  also  shows  the 
peritoneum  off  the  distended  and  high  bladder.  In  Chiara's  section 
only  a  small  portion  of  the  bladder  is  not  in  the  abdomen. 

While  the  higher  positions  of  the  pubic  segment  during  labour 
cannot  be  denied,  it  has  been  urged  that  it  is  only  the  bladder 
that  is  high,  and  that  further  the  bladder  may  be  regarded  as 
pushed  up,  not  drawn  up.  As  a  mere  matter  of  observation, 
however,  it  is  not  only  the  bladder  but  the  pubic  segment  that  is 
drawn  on.  Indeed  the  longitudinal  uterine  muscle  directly  passes 
to  the  cervix,  and  the  cervix  to  the  vaginal  walls,  which  bound  and 
form  part  of  the  segments.  Traction  on  them  is  therefore  direct,  and 
the  bladder  is  only  indirectly  drawn  up  by  its  attachment  to  the 
cervix  and  that  of  the  urethra  to  the  anterior  vaginal  wall. 

That  the  pubic  segment,  however,  is  drawn  up  and  not  pushed 
up  is  evident  when  we  come  to  consider — 

C.  The  action  of  the  retracting  uterine  muscle  on  the  pelvic  fioor 
segments. — Under  this  part  I  wish  briefly  to  consider  the  method 
of  action  of  the  uterine  muscle  during  labour  as  well  as  notice 
some  sections  of  early  labour  not  yet  alluded  to. 

The  dilatation  of  lower  uterine  segment,  cervical  canal,  and 
pelvic  floor  is  accomplished  by  the  upward  tension  exercised  by  the 
longitudinal  bundles  of  muscle  during  retraction  and  the  dilating 
power  of  the  foetus.  It  is  important  to  note  that  the  round  ligaments 
and  utero-sacral  folds  at  any  rate,  into  which  longitudinal  bundles 
pass,  give,  as  it  were,  external  fixed   points  for  uterine  action. 


1889.]  ANATOMY   OF   THE   FEMALE   PELVIC   FLOOR.  1099 

During  the  pain  these  external  points  seem  to  steady  the  uterus, 
and  allow  of  the  drawing  up  by  the  special  bundles  passing  to  the 
cervix.  In  the  early  stages  of  labour,  before  full  dilatation  can 
occur,  the  pelvic  floor  is  depressed  or  bulged  down,  as  Schroeder  and 
Barbour's  sections  show.  When,  however,  complete  canalization 
has  taken  place,  the  upward  tension  of  uterine  retraction  pulls  up 
the  pubic  segment  and  gives  it  the  higher  position  already  pointed 
out.  Were  it  not,  indeed,  for  the  upward  tension  exercised  by  the 
uterine  muscle  there  would  be  for  a  certainty  depression  and 
aversion  of  the  pubic  segment  before  the  advancing  head.  I  see, 
therefore,  in  all  recent  sections  abundant  confirmation  of  the  facts 
already  given  in  my  thesis  of  1880,  and  I  maintain  still  that  the 
pubic  segment,  in  which  I  of  course  include  the  bladder,  is  drawn 
up  in  part  into  the  abdomen  during  labour;  that  this  is  most 
marked  in  the  second  stage  of  labour ;  that  even  in  the  early  part 
of  the  first  stage  the  bladder  is  drawn  up  as  the  dilatation  of  the 
lower  uterine  segment  begins  (Saexinger's  section). 

In  sagittal  mesial  section  a  very  important  line  of  loose  tissue 
lies  between  posterior  vaginal  wall  and  anterior  rectal  one.  It 
is  here  that  the  posterior  boundary  of  displacement  in  prolapsus 
uteri  lies.  To  investigate  this  subject  more  fully  I  made  axial 
coronal  sections,  and  in  this  way  gained  fuller  information.  I 
found  loose  tissue  separating  the  pelvic  fascia  from  the  organs 
within  it,  viz. — bladder,  vagina,  and  anterior  wall  of  rectum.  As 
the  drawing  up  of  the  pubic  segment  was  a  displacement  of  only 
part  of  this  portion  lying  within  the  pelvic  fascia,  I  considered  it 
advisable  to  add  to  the  nomenclature  by  using  the  terms  "  entire 
displaceable  "  and  "  entire  fixed  "  segments.  The  entire  displace- 
able  segment  is  the  bladder  and  urethra  with  the  vaginal  walls. 
The  entire  fixed  portion  comprises  the  tissues  lying  beyond  the 
pelvic  fascia.  This  is  a  terminology  highly  useful,  as  it  puts  the 
matter  of  so-called  prolapsus  uteri  thus, — "  Prolapsus  uteri  is  a 
displacement  of  the  '  entire  displaceable '  portion  past  the  '  entire 
fixed '  portion." 

The  "  entire  fixed  "  portion  coincides  exactly  with  the  pelvic 
floor  of  some  anatomists.  In  the  axial  coronal  sections  one  can  see 
the  loose  side  relations  of  the  pubic  segment,  and  also  how,  beneath 
the  pubic  arch,  it  is  fixed  by  fascia  and  muscles.  This  fixation  I 
also  found  in  microscopical  sections. 

In  a  recent  communication  Dr  Symington  has  criticised  the 
conclusions  I  came  to  in  1880  in  the  following  terms : — 

"  I  consider  this  division  of  the  floor  to  be  a  very  convenient  one,  but  my 
own  investigations  have  failed  to  convince  me  of  the  existence  of  the  marked 
contrast  between  the  two  segments  described  by  Dr  Hart.     I  should  say  that ' 
the  texture  of  the  pubic  segment  is  on  the  whole  as  compact,  if  not  more  so, 
than  that  of  the  sacral.     Then,  again,  with  regard  to  their  attachments,  the 

J)ubic  segment  is  undoubtedly  firmly  attached  to  the  pubic  arch,  while  I  have 
ailed  to  find  any  strong  dovetailed  attachment  of  the  floor  to  the  sacrum  and 
coccyx. 


1100  DK   D.   BERRY   HART   ON   THE  [jUNE 

"  It  should  be  noticed  that  Dr  Hart  puts  the  bladder  in  the  pubic  segment. 
This  organ  is  undoubtedly  loosely  connected  with  the  anterior  wall  of  the 
pelvis,  and  his  description  would  be  correct  were  the  bladder  the  only  structure 
forming  the  pubic  segment.  I  do  not  consider  it  a  part  of  the  floor,  but  even 
though  it  be  regarded  as  such,  Dr  Hart's  description  is  not  applicable  to  the 
part  of  the  pubic  segment  situated  below  the  bladder. 

"  Dr  Hart  has  further  endeavoured  to  show  that  during  labour,  when  the 
pelvic  floor  is  opened  up  for  the  passage  of  the  child  through  it,  the  pubic  seg- 
ment is  drawn  upwards,  and  the  sacral  pushed  downwards  and  backwards. 
He  compares  the  process  to  passing  through  two  swinging  bank-doors.  '  One 
half  is  pulled  towards  the  passenger,  the  other  is  pulled  from  him.'  In  a 
Society  such  as  this,  I  am  reluctant  to  venture  an  opinion  on  a  subject  regard- 
ing which  I  have  no  clinical  experience.  As,  however,  Dr  Hart  bases  his  very 
ingenious  theory  largely  upon  Braune's  section  of  a  woman  in  labour,  I  may  be 
permitted  to  state  that  Braune's  drawing  does  not  appear  to  me  to  warrant  the 
deductions  Hart  has  drawn  from  it.  The  plate  (see  Fig.  6)  seems  to  me  to 
show  that  the  pubic  segment  (/)  is  pushed  downwards  and  forwards  imder  the 
pubic  arch.  The  urethra  may  be  somewhat  increased  in  length,  but  it  lies 
mainly  below  the  pubic  arch.  The  bladder  is  the  only  part  of  Hart's  pubic 
segment  that  is  not  depressed.  It  is  partly  flattened  up  against  the  symphysis, 
while  a  small  portion  (e)  lies  above  it." 

Dr  Symington  has  evidently  taken  his  views  of  the  texture  of  the 
pubic  segment  from  spirit  preparations.  In  fresh  preparations, 
however,  its  looseness  and  laxness  are  quite  evident.  Apart  from 
this,  it  is  recognised  clinically  by  every  gynecologist  during  the 
performance  of  the  bimanual.  Through  the  pubic  segment  the 
examiner  can  feel  and  map  out  the  uterus,  tubes,  and  ovaries  in 
many  cases,  and  can  feel  the  finger  tips  of  both  hands  easily.  This 
is  permitted  by  the  looseness  of  the  tissue  forming  this  special 
segment,  and  in  itself  sufficiently  refutes  Dr  Symington's  state- 
ment. As  to  the  firm  attachment  of  the  pubic  segment  below  the 
pubic  arch,  I  never  denied  that:  in  fact  it  is  a  well-known 
attachment  recognised  in  prolapsus  uteri,  and  shown  in  Schatz's 
section  of  prolapsus  uteri  (Arch,  filr  Gyn'ak.,  Bd.  xiii.,  S.  262; 
also  Contributions  to  Topographical  Anat.) 

In  regard  to  the  drawing  up  of  the  pubic  segment,  Dr  Symington's 
criticism  is  neither  a  correct  statement  of  the  method  of  research 
I  adopted,  nor  a  conclusion  based  on  anything  like  a  sufficient 
investigation  of  the  subject.  He  states  that  I  based  my  "ingenious 
theory  largely  on  Braune's  drawing."  I  may  first  object  that  there 
is  no  question  of  theory  in  the  matter ;  it  is  a  question  of  fact  based 
on  measurement.  I  further  based  my  conclusions  on  a  comparison 
of  the  three  sections  then  published ;  of  these,  Chiara's  shows  the 
most  marked  displacement  as  yet  figured,  and  Braune's  parturient 
section  is  drawn  with  such  accuracy  that  it  gives  more  detailed 
anatomy  of  the  displacement  than  any  other.  But  what  is  most 
remarkable  is,  that  Dr  Symington  actually  gives  his  opinion  ou 
the  displacement  of  the  pubic  segment  by  simple  inspection  of 
Braune's  parturient  section,  and  states  "  that  the  pubic  segment  is 
pushed  downwards  and  forwards  under  the  pubic  arch."  No  one 
can  say  this  from  mere  inspection  of  this  section  alone.     One  must 


interim-  vaainal  wall  at 


/e»ico-uterine  dip  ofperitone 


Posterior  vaginal  wall  at  end  o 


Posterior  vaginal  wall  during  early  labt 


raTtitnent  section 


1889.]  ANATOMY   OF   THE   FEMALE   PELVIC   FLOOK.  1101 

compare  it  with  pregnancy  sections  as  I  have  done.  When  one 
does  so,  it  is  at  once  evident  that  Dr  Symington's  statement  on 
this  point  is  erroneous.  Dr  Symington  has  thus  given  his 
opinion  on  this  point  without  examining  all  the  sections  published 
in  1880,  to  say  nothing  of  the  many  issued  since. 

The  term  "  dovetailed  into  the  sacrum "  is  quite  accurate,  and 
means,  in  a  literary  sense,  an  attachment  to  both  sides  of  a  structure. 
If  plates  iii.,  iv.,  ix.,  and  x.  in  my  Atlas  of  1885  be  consulted  it  will 
easily  be  seen. 

The  lithographic  plate  shows  Braune's  parturient  section  super- 
imposed on  the  pregnant  section,  and  sufficiently  explains  itself. 


IV.  -FCETAL  MALARIA,  AS  ILLUSTRATED  BY  TWO  CASES. 

By  R.  W.  Felkin,  M.D.,  F.R.S.E.,  Lecturer  on  Diseases  of  the  Tropics  and 
Climatology,  Edinburgh  School  of  Medicine. 

{Bead  before  the  Obstetrical  Society  of  Edinburgh,  \3th  Febrimry  1889.) 

It  has  long  been  recognised  as  a  fact  that  a  foetus  in  utero  can 
suffer  from  a  paroxysm  of  malarial  fever,  and  ague-cake  in  the 
fcetus  is  perfectly  familiar  to  those  who  have  practised  in  tropical 
countries.  To-night  I  am  bringing  forward  two  cases  of  an 
unusual,  or,  at  any  rate,  I  believe,  an  unrecognised  character. 

At  an  interval  of  some  years  I  have  met  with  two  cases  of  foetal 
malaria  (amongst  numerous  examples  of  the  ordinary  kind)  in 
which,  to  the  best  of  my  knowledge,  the  mothers  were  entirely 
free  from  the  disease,  so  that  the  question,  Can  a  father  transmit 
malaria  to  a  foetus  ?  has  now  to  be  considered. 

The  first  case  I  saw  in  1880  in  South  Africa,  the  other  I  met 
with  last  year  in  Edinburgh.  Before  making  a  few  remarks  on 
these  cases,  I  will  read  my  recorded  notes. 

In  1880  I  was  staying  in  a  small  place  near  Durban  in  South 
Africa.  One  night  I  was  called  up  and  asked  if  I  would  attend  a 
lady  staying  in  the  same  house  who  had  been  taken  suddenly  ill. 
She  complained  of  pain  and  of  a  curious  sensation  in  her  abdomen, 
and  said  that  she  was  over  eight  months  pregnant.  On  palpating 
her  abdomen,  I  distinctly  felt  the  foetus  shaking.  The  lady  told 
me  that  the  same  thing  had  occurred  on  several  previous  occasions, 
but  never  so  severely  as  now,  nor  had  she  previously  experienced 
pain.  The  next  night,  and  again  the  next,  the  same  thing  occurred 
at  the  same  hour,  and  the  following  history  was  given  to  me  by 
the  lady's  husband.  He  had  been  employed  for  several  years  on 
the  west  coast  of  Africa,  and  had  suffered  severely,  both  from 
intermittent  and  remittent  fever, — so  much  so,  indeed,  that  he 
decided  to  throw  up  his  employment  and  to  try  a  change  of 
climate  at  the  Cape  after  a  holiday  in  Madeira,  where  he  obtained 
a  temporary  situation.     Whilst  in  that  island  he  met  his  wife  and 


1102  DR   R.   W.   FELKIN   ON   FCETAL  MALARIA.  [jUNE 

married  her.  She  was  a  Lancashire  lady.  They  remained  for 
some  eight  months  subsequent  to  their  marriage  in  Madeira,  and 
arrived  at  Durban  about  a  week  before  I  met  them.  She  had 
never  suffered  from  malaria  in  any  form  whatever.  The  husband 
still  had  occasional  attacks  of  intermittent  fever,  and  he  told  me 
that  just  previous  to  his  marriage,  and  for  the  first  month  after,  he 
had  had  several  very  severe  attacks.  On  the  fourth  niglit  I  was 
again  summoned  to  my  patient,  and  found  that  the  child  was 
again  shaking  violently.  At  the  same  time  I  ascertained  that 
labour  had  commenced.  On  examination  I  found  that  the  os  was 
as  large  as  a  five-shilling  piece,  the  head  was  presenting,  and  all 
apparently  going  on  well.  Until  the  head  arrived  on  the  perineum 
the  labour  was  satisfactory,  but  from  this  time,  although  the  pains 
had  been  fairly  strong,  no  progress  was  made.  After  waiting  some 
time,  as  the  patient  was  getting  exhausted,  I  put  on  forceps  and 
delivered  the  head  with  more  difficulty  than  I  had  expected,  and 
I  had  very  great  difficulty,  indeed,  in  delivering  the  body  on 
account  of  the  greatly  distended  abdomen,  caused  by  an  enlarged 
spleen.  In  spite  of  all  my  care,  the  perineum  was  slightly  torn 
during  its  delivery.  The  further  progress  of  this  case  is  of  little 
interest.  All  went  on  well,  and  I  subsequently  heard  that  the 
child  was  thriving,  that  the  spleen  had  been  reduced  to  about 
normal  size,  and  that  after  birth  the  child  had  only  had  seven 
attacks  of  ague.  I  only  saw  one  of  these  attacks,  which  was  very 
well  marked,  the  cold,  hot,  and  sweating  stages  being  all  present. 
The  paroxysm  lasted  about  seven  hours,  but  unfortunately  I 
cannot  find  a  note  of  the  temperature.  If  memory  serves  me 
right,  the  highest  temperature  during  the  paroxysm  was  rather 
over  102°  F.  in  the  rectum. 

Now,  if  this  case  had  occurred  alone,  I  do  not  think  I  should 
have  brought  it  under  your  notice,  although  I  consider  it  is  a 
fairly  conclusive  one.  It  might,  however,  be  objected  by  some 
that  it  was  just  possible  that  the  mother  might  in  some  way  or 
other  have  become  infected  by  malaria,  although  she  had  mani- 
fested no  symptoms.  The  next  case,  I  believe,  precludes  all  such 
possibility. 

On  the  3rd  of  January  1888  I  was  called  to  see  Mrs  H.,  who 
was  suffering  from  pleurisy  and  bronchitis,  and  from  the  effects  of 
a  severe  beating  which  she  had  received  from  her  husband.  She 
was  extremely  ill,  and  a  charitable  lady  who  took  an  interest  in 
her  got  her  a  nurse.  On  the  5th  of  January  the  nurse  told  me 
that  the  woman  was  pregnant,  and  that  at  ten  o'clock  on  the 
previous  evening  she  had  complained  of  pain  and  "  fluttering  "  in 
her  abdomen.  The  nurse  described  it  as  being  like  a  bad  quicken- 
ing, and  said  it  lasted  for  about  an  hour,  I  told  her  to  send  for 
me  should  it  occur  again,  and  I  was  sent  for  the  same  evening  at 
10.30.  On  examining  the  patient  I  was  forcibly  reminded  of  the 
case  above  described.     On  January  7th,  at  the  same  time,  after 


1889.]  DR   E.   W.   FELKIN   ON   FCETAL  MALARIA.  1103 

another  similar  paroxysm,  labour  came  on,  and  the  child  was  born 
about  half  an  hour  before  I  arrived.  It  was  very  feeble,  about  a 
seven-and-a-half  month  child,  with  a  slightly  enlarged  abdomen. 
We  managed  to  keep  it  alive  for  forty-eight  hours,  and  it  died  on 
the  9th  of  January  at  11  p.m.  in  the  cold  stage  of  ague,  the  second 
attack  it  had  had  since  birth.  The  attack  of  ague  on  the  8th 
commenced  shortly  before  11  o'clock.  The  cold  stage  was  very 
well  marked,  the  child  distinctly  shivering,  and  continuing  to  do 
so  for  rather  more  than  half  an  hour.  The  hot  stage  lasted  about 
two  hours,  and  was  followed  by  fairly  profuse  perspiration,  the 
cotton-wool  in  which  the  child  was  wrapped  becoming  quite  wet 
During  the  attack  the  temperature  was  taken  several  times,  and 
the  highest  point  reached  was  102-6. 

On  inquiry,  I  ascertained  the  following  facts: — The  child's 
parents  had  been  married  twelve  years.  The  mother  had  never 
been  away  from  Edinburgh.  Three  children  had  all  been  born  at 
full  time  and  quite  healthy  during  the  first  seven  years  after  the 
parents'  marriage.  The  father  then  went  as  fireman  on  a  steamer 
trading  with  West  African  ports.  The  men  were  forbidden  to 
land  at  the  ports,  but  the  second  engineer  and  this  fireman 
managed  to  escape  several  times,  and  had  severe  remittent  fever. 
The  engineer  died,  and  his  death  so  frightened  the  fireman  that  he 
did  not  go  on  shore  again,  although  he  remained  another  year  in 
the  service  suffering  from  ordinary  ague.  He  had  never  suffered 
from  syphilis.  Ten  months  after  his  return  home  a  child  was 
born  at  full  time,  but  it  soon  "  pined  away  and  died."  Eather 
more  than  a  year  later  another  child  was  born.  It  has  always  been 
ailing,  and  has  a  rather  enlarged  spleen.  Appropriate  treatment 
has  greatly  improved  this  child,  and  now  (1889)  it  is  fairly  well. 
Lastly,  the  child  I  have  referred  to  was  born.  In  all  her  last 
three  pregnancies,  the  mother  assured  me  that  she  had  suffered 
from  the  curious  feelings  I  have  mentioned,  and  her  friends  had 
joked  her  about  quickening  so  often. 

With  regard  to  this  case,  there  is  no  doubt  in  my  mind  that  the 
foetus  suffered  from  ague,  that  the  mother  had  never  had  ague,  and 
that  the  father  had  transmitted  the  disease  to  no  less  than  three 
infants.  Unfortunately  the  woman  died  ten  days  after  the  birth  of 
the  last  child.  The  nurse  had  occasion  to  go  out  for  a  few  hours ; 
the  woman  drank  a  bottle  or  more  of  whisky,  became  exceedingly 
ill,  and  Dr  Hare,  who  kindly  saw  her  for  me,  sent  her  to  the 
Infirmary,  where  she  died  soon  after  admission,  and  unfortunately 
no  post-mortem  was  obtained. 

Dr  Woodhead  has  had  the  kindness  to  have  sections  of  the  liver, 
spleen,  and  kidneys  of  the  child  cut  for  me.  The  specimens  you 
will  be  able  to  see  under  the  microscope. 

Dr  A.  Bruce  has  been  good  enough  to  examine  them  for  me, 
and  to  give  me  the  following  report : — 

Kidney. — The    epithelium    of    the    convoluted    tubules    shows 


1104  DR  R.   W.   FELKIN   ON   FCETAL   MALARIA.  [jUNE 

marked  cloudy  swelling,  the  nuclei  of  the  cells  continuing  to 
stain,  while  the  surrounding  protoplasm  is  highly  granular,  and  so 
swollen  as  to  occupy  the  whole  lumen  of  the  tubules.  The  nuclei 
of  the  cells  of  the  glomeruli  stain  with  great  distinctness;  the 
glomerular  capillaries  seem  dilated. 

Liver. — The  capillaries  are  much  dilated  and  engorged  with  blood. 
The  white  corpuscles  seem  to  contain  very  numerous  fine  granules 
of  a  dark  brown  and  black  colour.  These  granule-carrying  leuco- 
cytes form  a  very  distinct  feature  on  the  field ;  they  are  the  first 
thing  that  attracts  the  eye  of  the  observer.  The  liver  cells  are 
somewhat  cloudy. 

Spleen. — The  spleen  is  congested,  the  venous  sinuses  being  con- 
siderably dilated.  On  the  field  large  numbers  of  the  leucocytes 
in  the  sinuses,  the  endothelial  cells  in  their  walls,  and  the 
large  connective  tissue  cells  of  the  pulp  contain  fine  pigment 
granules,  identical  with  those  observed  in  the  liver.  The  Mal- 
pighian  bodies  appear  to  be  fairly  normal. 

I  think  that,  apart  from  the  intrinsic  interest  of  these  cases  and 
the  comparative  rarity  of  meeting  with  foetal  malaria  in  this 
country,  the  cases  have  a  great  importance ;  for  they  seem  to  me 
very  clearly  to  prove  that  malaria  is  a  specific  disease,  that  it  is 
due  to  a  micro-organism  and  not  to  chill,  as  some  would  have  us 
even  yet  believe.  How  could  any  amount  of  chill  from  which  the 
fathers  might  have  suffered  be  transmitted  in  the  way  I  have  indi- 
cated ?  And  I  think  it  is  well  to  bring  forward  such  cases  as  these, 
in  order  to  keep  the  question  as  to  the  origin  of  malaria  before  the 
profession.  It  is  not  my  intention  to-night  to  enter  into  the 
general  etiology  of  malaria,  as  I  hope  shortly  to  enter  into  it  more 
fully  in  another  place.  All  I  wish  to  do  is  to  introduce  for  dis- 
cussion one  point,  namely,  the  possibility  of  a  non-malarious 
woman  producing  a  malarious  child. 

It  is  an  admitted  fact  that  the  foetus  in  utero  may  suffer  from 
syphilis,the  ovumbeingdirectlyinfected  by  the  father,  and  the  mother 
escaping.  With  regard  to  the  transmission  of  syphilis  from  the 
father  to  the  foetus,  the  mother  remaining  unaffected,  Mr  Jonathan 
Hutchinson  says : — "  The  evidence  on  this  point  seems  to  be  over- 
whelming. It  is  a  matter  of  constant  experience  that  the  father  of  a 
syphilitic  infant  is  known  to  have  had  the  disease  before  marriage, 
whilst  not  a  symptom  has  ever  been  observed  in  his  wife.  ...  In 
these  cases  it  frequently  happens  that  the  taint  in  the  father  is 
wholly  latent,  that  he  has  for  long  appeared  to  be  absolutely  well, 
...  it  being  then  taken  as  established  that  the  child  may  at  the 
time  of  conception  take  syphilis  from  its  father  alone."  But  in 
neither  of  my  cases  was  the  disease  latent ;  it  was  active.  There- 
fore I  think  the  possibility  of  the  father  affecting  the  foetus  may 
be  the  more  readily  granted.  Again,  speaking  of  syphilis,  Mr 
Hutchinson  says : — "  The  transmission  of  the  disease,  as  well  in 
inheritance  as  in  acquisition,  is  always  effective  by  the  conveyance 


1889.]  DK   R.   W.   FELKIN   ON   FfETAL   MALAKIA.  1105 

from  person  to  person,  not  of  a  tendency  to  disease,  but  of  a  par- 
ticulate virus.  The  virus  is  probably  as  specific  and  individual  as 
are  the  seeds  of  barley  or  of  clover.  If  it  passes  into  the  sperm  or 
germ,  then  the  foetus  is  liable  to  the  full  development  of  the  dis- 
ease ;  and  if  it  chance  that  none  of  its  elements  do  so  pass,  then 
the  offspring,  although  born  to  a  tainted  parent,  escapes  free." 
The  facts  stated  by  Hutchinson,  "that  a  woman  who  bears  a 
syphilitic  foetus  inheriting  from  its  father,  although  herself  remain- 
ing free  from  symptoms,  acquires  silently  a  state  of  constitution 
which  protects  her  from  syphilis  in  the  future,"  is,  I  think,  a  proof 
that  some  day  preventive  inoculation  will  be  practised  against 
syphilis,  and  for  malaria  too,  if  my  observations  and  belief  be 
right. 

Machiafava  and  Celli  have  now  placed  on  record  five  cases,  in 
which  the  injection  of  about  one  gram  of  malarial  blood  induced 
well-marked  malarial  fever,  possessing  the  same  type  and  the  same 
symptoms  in  the  patients  inoculated  as  in  those  from  whom  the 
blood  was  taken,  and  in  each  case  the  characteristic  alteration  was 
found  in  the  blood  of  the  persons  inoculated  as  well  as  in  the  blood 
of  the  patients  undoubtedly  suffering  from  malaria.  It  is  also 
certain  that  when  once  a  man  has  suffered  from  malaria  of  what- 
ever kind,  he  is  liable  to  attacks  for  the  rest  of  his  life.  These  and 
other  facts,  too  numerous  to  mention,  incline  me  to  the  belief  that 
it  is  just  as  possible  for  malaria  to  be  produced  in  a  foetus  in  utero, 
in  the  way  I  have  indicated,  as  it  is  for  other  diseases,  the  trans- 
mission of  which  is  now  undisputed. 


v.— AN  EXAMINATION  OF  THE  PHENOMENA  IN  CHEYNE- 

STOKES  RESPIRATION. 

By  G.  A.  Gibson,  M.D. 

(  Continued  from  page  1030.) 

In  a  case  of  thoracic  aneurism  in  an  old  man,  described  by  de 
C^renville,^  Cheyne- Stokes  respiration  was  present  for  some  days. 
No  mention  is  made  of  the  state  of  the  pulse  in  the  varying  phases 
of  the  breathing,  but  the  pupils  are  said  to  have  remained  in  a 
condition  of  excessive  contraction.  The  author  takes  the  oppor- 
tunity of  bringing  forward  an  occurrence  which  seems  to  be  unique 
— a  case  of  intermittent  respiration  in  a  baby,  one  month  old,  caused 
by  morphine  taken  by  his  mother.  The  mother  had  been  suffering 
from  neuralgia,  for  which  she  took  a  large  dose  of  morphine,  and 
next  day  the  baby  lost  his  appetite,  became  cyanotic,  and  fell  into 
convulsions,  attended   by  periodic   breathing,  during  which  the 

^  Bulletin  de  la  Society  mMicale  de  la  Suisse  romande,  dixifeme  annde,  p.  152, 
1876.  (This  contribution  only  came  to  my  knowledge  recently,  and  it  has 
therefore  not  been  taken  in  its  proper  order.) 

EDIXBURGH    MED.    JOUBN.,   VOL.    XXXIV. — JfO.    XII.  7   A 


1106  DR   G.   A.   GIBSON   ON   THE  [jUNE 

pupils  varied  in  size,  becoming  larger  with  inspiration.  The  infant 
recovered  under  appropriate  treatment.  In  a  case  of  cardiac  dis- 
ease presenting  Cheyne-Stokes  respiration,  de  Cerenville  found 
that  morphine  caused  a  diminution  in  the  extent  of  the  respiratory 
phenomenon,  while  neither  digitalis  nor  bromide  of  potassium  had 
any  effect  of  the  kind. 

Cantieri^  records  a  case  of  cardiac  disease  in  a  man  aged  59, 
who  presented  the  symptom  of  Cheyne-Stokes  respiration  during 
the  course  of  the  affection.  After  death  it  was  found  that  there 
was  great  hypertrophy  of  the  heart  with  pericarditis,  myocarditis, 
and  endocarditis — the  latter  especially  affecting  the  left  side  and 
particularly  the  mitral  valve — associated  with  atheroma  of  the 
aorta. 

Bordoni^  describes  two  cases  presenting  Cheyne-Stokes  respira- 
tion, one  being  that  recorded  by  Cantieri,  which  has  just  been 
referred  to,  and  the  other  patient  being  a  man  aged  76,  who  died 
under  the  care  of  a  colleague  in  consequence  of  pneumonia  and 
cardiac  degeneration.  In  the  former  case  the  pulse  increased  in 
rate  and  tension  during  the  pause;  the  pupil  contracted  during  that 
phase,  and  dilated  during  the  period  of  breathing.  In  the  latter 
case  the  rate  and  tension  were  greater  during  the  period  of  breath- 
ing than  during  the  pause,  and  there  were  no  periodic  changes  in 
the  size  of  the  pupils.  Bordoni  mentions  several  of  the  writers 
who  have  concerned  themselves  with  Cheyne-Stokes  breathing, 
but  restricts  himself  to  facts,  and  abstains  from  making  any 
theoretical  remarks. 

Oser^  describes  the  occurrence  of  this  form  of  respiration  in  a 
woman  aged  74,  suffering  from  aortic  and  mitral  disease.  The 
symptom  occurred  during  an  attack  of  intestinal  catarrh,  and  again 
a  few  days  before  death ;  and  it  is  noteworthy  that  it  could  at  any 
time  be  produced  when  it  was  not  present  by  compression  of  the 
two  common  carotid  arteries.  At  the  post-mortem  examination, 
besides  the  cardiac  lesions,  nothing  but  the  usual  senile  changes 
could  be  found,  along  with  some  discoloration  of  the  medulla 
oblongata  and  upper  part  of  the  spinal  cord. 

Howard,*  in  a  paper  on  some  of  the  varieties  of  dyspnoea  met 
with  in  kidney  disease,  after  referring  to  the  appearance  of  Cheyne- 
Stokes  respiration  in  one  of  his  puerperal  cases,  suffering  from 
ursemic  eclampsia,  briefly  describes  its  occurrence  in  a  man,  52 
years  old,  who  was  the  subject  of  chronic  renal  disease.  The  chief 
interest  of  the  case  lies  in  the  fact  that  the  periodic  breathing  had 
persisted  for  two  months  before  the  author  saw  him  in  consultation 
with  another  medical  man,  and  that  there  was  no  appearance  of 

^  Bolletino  della  Societd  tra  i  Gultori  delle  Scienze  mediche  in  Siena,  anno  ii. 
p.  250,  1884. 

^  Ibid.,  anno  ii.  p.  253,  1884. 

^  Wiener  medizinische  Blatter,  vii.  Band,  S.  1480,  1884. 

*  Canada  Medical  and  Surgical  Journal,  vol.  xiii.  p.  193,  1884. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   KESPIRATION.  1107 

imminent  danger  when  he  was  seen.  Howard  mentions  another 
case  in  which  he  had  observed  Cheyne-Stokes  breathing,  an  aged 
man  sinking  apparently  from  senile  decay.  He  is  now  inclined  to 
think  that  failure  of  the  renal  functions  may  have  been  the  imme- 
diate occasion  of  the  symptom,  and  suggests  that  this  is  probably 
the  underlying  cause  of  the  symptom  in  many  cases.  The  author 
makes  passing  reference  to  the  work  of  Cuffer,  but  shrinks  from 
entering  into  any  discussion  of  the  numerous  explanations  that 
have  been  advanced. 

Mosso,  in  an  exhaustive  monograph,^  has  materially  contributed 
to  the  knowledge  we  possess  of  this  symptom.     He  begins  by 
pointing  out  that  the  movements  of  respiration  are  not  always 
uniform  and  regular.     In  profound  repose  and  more  especially 
deep  sleep  of  man  and  animals,  the  respirations  are  grouped  in 
periods,  and  this  periodic  breathing  is  quite  physiological.     When 
this  periodic  respiration  becomes  more  intense,  pauses  appear  from 
the  remission  or  cessation  of  inspiration,  and  the  author  terms  such 
breathing  remittent  when  there  is  a  slight  respiratory  movement 
during  a  pause,  and  intermittent  when  there  is  complete  cessa- 
tion for  a  time.     He  mentions  breaks  in  breathing,  as  if  a  respira- 
tion had  aborted  or  failed,  but  points  out  that  there  is  no  connexion 
between  such  a  break  and  the  succeeding  respirations.     Inter- 
mittent respiration  may  be  caused  by  injections  of  chloral,  and  this 
cannot  be  modified  by  making  the  animal  breathe  pure  oxygen 
through   the   tracheal   canula,  nor  by  artificial  respiration  from 
electric  stimuli  to  the  respiratory  nerves ;  and  the  author  concludes 
that  the  intermittences  cannot  be  modified  by  the  influence  of 
oxygen.     He   states   that   there   are   periods   of   tonicity   of   the 
respiratory  muscles  independently  of  the  rhythmic  movements  of 
breathing,  and  that  the  circulatory  vessels  take  no  part  in  the 
phenomena  of  periodic  breathing,  which  disposes  of  the  complicated 
and  imaginary  theories  of  Traube,  Filehne,  and  others.     Oscilla- 
tions in  the  tonicity  of  the  respiratory  muscles  are  closely  united 
with  the  phenomena  of  periodic  breathing.     In  general,  when  this 
tonicity  is  lessened  there  is  a  tendency  on  the  part  of  the  respira- 
tory centre  to  lessen  the  force  of  the  movements  of  respiration,  and 
a  pause  often  ensues.     It  has  been  thought  that  the  greater  or  less 
activity  of  the  respiratory  centre  represents  a  greater  or  less  need 
of  provision  by  pulmonary  ventilation  for  the  chemical  wants  of 
the  organism ;  but  the  author  is  of  opinion  that  he  is  not  far  from 
the   truth  in  thinking  that  the   respiratory  movements   modify 
themselves   according   to   the   states   of  sleeping   or   waking,  of 
greater  or  less  activity  of  the  nervous  system.     He  holds  that  the 
mechanical  and  chemical  parts  of  respiration  are  distinct,  that  the 
mechanical  is  more  representative  of  the  vitality  of  the  nerve 
centres  than  of  the  chemical  wants  of  the  organism ;  that  if  the 

^  Atti  delta  Reale  Accademia  dei  Lincei,  anno  cclxxxii.,  1884-86,  serie  qiiarta, 
p.  457,  1885  ;  and  Archives  italiennes  de  Biologie,  tome  vii.  p.  48,  1886. 


1108  DR   G.    A.   GIBSON   ON   THE  [jUNE 

nervous  excitability  increases  more  air  is  inspired  than  is  needed 
for  chemical  wants,  while  on  the  contrary  during  sleep  the 
mechanical  may  lessen  or  become  periodic  without  disturbance  of 
the  chemical  function  of  tissue  respiration  ;  and  further,  that  when 
the  excitability  of  the  centres  is  much  lowered,  it  can  be  deter- 
mined that  the  accumulation  of  carbonic  acid  by  asphyxia  causes 
almost  no  effect  on  the  respiratory  movements. 

Mosso  agrees  with  Fano  in  hesitating  to  accept  the  hypothesis 
of  Luciani,  but  does  not  see  how  Fano's  hypothesis  can  explain 
remittent  respiration,  for,  if  it  were  true,  periodic  breathing  would 
always  appear  in  animals  whose  nervous  excitability  gently  died 
away,  which  it  does  not.  He  points  out  that  the  ascending  part 
of  the  breathing  is  not  due  to  arterialization  of  the  blood,  for  it 
appears  just  as  before  after  the  diaphragm  has  been  cut,  so  as  to 
render  the  respiration  useless.  The  periods  of  breathing  appear 
during  sleep  without  any  consciousness.  The  pauses  have  no  effect 
on  the  vaso-motor  centre  if  they  are  not  very  long.  If  any  influence 
is  shown,  it  is  opposite  in  effect  to  that  of  psychic  phenomena ; 
during  the  intermittences  there  is  a  diminution  in  the  tonicity  of 
the  bloodvessels,  while  under  the  influence  of  psychic  activity 
there  is  an  increase.  Referring,  again,  to  the  hypothesis  of  Filehne, 
he  says  it  is  a  mere  supposition,  and  adds  that  his  results  are  con- 
trary to  his  hypothesis.  He  has  observed  the  fact  described  by 
Murri,  that  during  the  pause  there  is  an  increase  in  the  bulk  of  the 
arm  as  tested  by  the  plethysphygmograph,  and  is  of  opinion  that 
it  is  caused  by  dilatation  of  vessels  during  profound  slumber. 

Although  periodic  respiration  is  not  in  direct  or  immediate  re- 
lation with  vascular  phenomena,  alterations  in  the  circulation  of 
the  nervous  centres  may  cause  periodic  respiration ;  in  chloralized 
animals  it  appears  on  raising  the  head,  and  disappears  when  the 
head  is  again  lowered. 

Mosso  points  out  the  intimate  relations  of  periodic  breathing 
with  sleep,  as  shown  by  the  variations  of  the  iris  and  the  intelli- 
gence. In  discussing  the  phenomena  of  consciousness  he  points 
out  that  there  is  no  distinction  in  kind,  simply  a  variation  in 
degree.  He  refers  to  a  case  under  the  care  of  his  colleague, 
Bozzolo,  where  all  the  reflexes,  even  those  of  swallowing,  were 
abolished  during  the  pause.  He  does  not  believe  that  all  cases 
are  due  to  conditions  resembling  sleep ;  he  has  seen  it,  for  instance, 
under  the  influence  of  curara,  where  the  arrest  of  the  respiratory 
movements  caused  by  the  motor  paralysis  produced  sufficient 
excitement  of  the  nervous  activity  to  overcome  the  influence  of 
the  curara  on  the  nerves. 

Davies^  gives  an  explanation  by  Foster  of  a  case  in  which  it  was 
noted  "  that  the  heart  and  respiration  alternated  in  rhythm, the  heart 
being  in  full  swing  at  the  pause  of  the  respiration,  and  being  in- 
hibited during  the  height  of  the  respiratory  period."     This  circum- 
1  Lancet,  vol.  i.  for  1885,  p.  1183. 


1889.]  PHENOMENA  IN   CHEYNE-STOKES   RESPIRATION.  3109 

stance  is  explained  by  Foster  as  follows : — "  Apparently  coincident 
with  changes  in  the  medulla  oblongata  leading  to  Cheyne-Stokes 
respiration  was  a  stimulation  of  the  cardio-inhibitory  centre  in  the 
medulla,  occurring  alternately  with  the  former." 

Fazio ^  has  described  Cheyne-Stokes  respiration  as  a  symptom 
occurring  in  the  course  of  cholera. 

Langendorff  ^  points  out  that  a  change  from  regular  to  periodic 
rhythm  is  not  peculiar  to  the  respiration,  and  as  examples  of 
similar  change  of  rhythm  mentions  the  frog's  heart  nourished 
by  means  of  serum  instead  of  blood;  the  ventricle  of  the  frog's 
heart  separated  from  the  auricle;  and  the  heart  of  the  embryo 
of  the  fowl.  He  then  starts  from  the  point  of  view  that  the 
commonest  cause  of  the  periodicity  of  rhythmic  movement  is 
asphyxia,  and  seeks  to  determine  whether  it  can  be  produced  ex- 
perimentally in  this  way.  In  mammals  asphyxia  is  too  rapid  to 
induce  periodic  breathing,  but  in  frogs,  as  he  showed  before,  he  is 
able  to  do  so.  He  calls  attention  to  the  increased  motor  activity 
during  the  period  of  breathing,  which  may  even  reach  the  stage  of 
convulsions.  Frogs  poisoned  by  strychnine  and  then  asphyxiated 
show  convulsions  during  the  breathing.  The  movements  appear 
even  after  the  removal  of  the  brain,  and  cannot  therefore  be 
voluntary.  It  has  been  observed,  further,  that  before  the  respira- 
tory period  the  heart  and  lymph-hearts  cease  for  a  time  to  beat. 
Langendorff  interprets  the  various  manifestations  of  activity  asso- 
ciated together  in  an  attack  as  being  the  co-ordinated  effects  of  a 
periodic  excitement  of  the  gray  substance  of  the  brain  and  cord. 
But  in  order  to  explain  this  periodicity  in  the  Cheyne-Stokes 
phenomenon  it  is  necessary  to  admit  some  opposition  to  the  normal 
stimulation,  and  the  author  regards  the  lowered  irritability  of  the 
respiratory  centre  in  this  light. 

Bernabei^  records  a  case  in  which  Cheyne-Stokes  breathing 
made  its  appearance  as  a  symptom  of  meningitis  following  fracture 
of  the  temporal  bone. 

Wellenbergh*  begins  a  valuable  and  interesting  contribution  to 
the  study  of  Cheyne-Stokes  respiration  by  a  consideration  of  the 
anatomical  relations  of  the  respiratory  centre  and  nerves,  and  of 
the  bloodvessels  which  supply  the  nerve  centres.  He  shows  that 
the  quantity  of  blood  within  the  skull  may  increase  or  decrease 
under  certain  circumstances,  and  that  such  changes,  when  com- 
pensated by  movements  of  the  cerebro-spinal  fluid,  may  not  inter- 
fere with  the  physiological  balance  of  function ;  but  that  beyond 
a  certain  point  such  alterations  in  the  blood-supply  must  produce 
disturbances.     This  leads  him  to  draw  an  analogy  between  certain 

*  Rivista  Clinica  e  Terapeutica,  1885. 

2  Breslauer  arztliche  Zeitschrift,  vii.  Band,  S.  161,  1885,  and  Biologisches 
Centralblatt,  vi.  Band,  S.  370,  1887. 

3  Bolletino  della  Societd  tra  i  Cultori  delle  Scienze  mediche  in  Siena,  anno  iii., 
1885. 

*  Psychiafrische  Bladen,  iii.  Jaargang,  S.  30,  1885. 


1110  DR  G.   A.   GIBSON   ON   THE  [jUNE 

mechanical  contrivances  and  the  probable  causes  of  Cheyne-Stokes 
respiration.  He  imagines  a  brook  whose  stream  moves  a  wheel,  the 
motion  of  which  is  transmitted  by  means  of  an  endless  rope  to  the 
sails  of  a  mill.  He  compares  the  brook  to  a  bloodvessel,  the  water 
to  the  blood,  the  wheel  to  the  respiratory  centre,  and  the  revolu- 
tions of  the  sails  to  the  respiratory  movements.  He  then  imagines 
such  an  obstacle  to  the  flow  of  the  brook  as  a  lock  with  a  trap- 
door, whose  resistance  is  greater  than  the  pressure  of  the  water, 
in  consequence  of  which  the  door  cannot  open  until  the  accumu- 
lating water  has  sufficient  pressure  to  overcome  the  resistance. 
Before  the  trap  opens  the  water  beyond  the  lock  will  have  flowed 
away  and  the  wheel  will  have  gradually  stopped.  As  soon  as  the 
pressure  of  the  water  has  overcome  the  resistance  of  the  trap  the 
water  will  flow  down  the  brook  in  greater  quantity  and  with 
greater  force  than  under  ordinary  circumstances.  The  brook  will 
be  filled,  the  wheel  will  revolve,  at  first  slowly,  but  afterwards 
with  greater  velocity  than  under  ordinary  circumstances,  and  as 
the  brook  falls  to  its  usual  size  the  rate  will  lessen  until,  from  the 
closure  of  the  trap,  the  stream  again  fails  and  the  wheel  stops. 
This  is  represented  by  a  graphic  schema,  in  which  the  wheel  re- 
volves normally  three  times  a  minute,  as  follows  : — 


Fio.  1.— The  figures  1  to  5  represent  the  number  of  revolutions  per  minute,  and  the  asterisk 
denotes  the  moment  when  the  trap-door  is  closed. 

The  amount  of  resistance  of  the  trap-door  and  the  amount  of 
pressure  of  the  flowing  water  are  the  two  factors  upon  which  the 
endless  varieties  which  the  tracing  may  undergo  depend,  the  size 
of  the  wheel  remaining  constant. 

The  schematic  tracing  reproduced  above  is  then  compared  by 
the  author  with  tracings  from  the  chests  of  patients  showing 
Cheyne-Stokes  respiration. 

The  author  finds  that  although  there  is  no  apparatus  within  the 
vessels  analogous  to  the  lock  and  trap-door,  there  is  an  external 
force,  viz.,  intracranial  cedema,  and  he  regards  intracranial 
oedema  as  the  principal,  if  not  the  only  cause  of  Cheyne-Stokes 
respiration.  He  regards  the  phenomenon  as  the  result  of  a 
struggle  between  the  pressure  of  the  blood  within  the  vessels  and 
the  pressure  of  the  cedema  outside  of  them,  a  struggle  in  which 
these  forces  are  alternately  supreme. 

He  thereupon  compares  the  appearances  accompanying  Cheyne- 
Stokes  breathing  with  the  symptoms  which  would  naturally  be 
expected  to  follow  an  alternate  inorease  and  decrease  of  pressure, 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION,  1111 

and  is  strengthened  in  his  views  by  the  comparison.  The  author 
afterwards  reviews  a  number  of  the  theories  which  have  been 
advanced,  and  concludes  that  the  series  of  symptoms  can  hardly 
be  caused  but  by  such  a  cause  as  he  has  supposed. 

Murri^  combats  the  opinion  of  Mosso  that  Cheyne-Stokes 
respiration  presents  a  condition  analogous  to  sleep.  During 
sleep  the  respiratory  movements  may  cease  without  any  injury 
to  the  interchange  of  gases  in  the  tissues  and  blood,  because  there 
is  less  need  for  oxygenation.  Eemittent  and  intermittent  respira- 
tion accordingly  appear  where  a  condition  analogous  to  sleep  is 
developed  in  the  central  nervous  system.  There  is  lowering  of 
the  irritability  of  the  medulla  oblongata,  and  Mosso  differs  from 
other  observers  in  his  opinion  that  in  this  lessened  irritability 
there  is  a  state  analogous  to  sleep,  whence  intermittent  breathing 
is  a  physiological  appearance  instead  of  a  rare  phenomenon.  He 
therefore  seeks  to  draw  the  conclusion  that  Cheyne-Stokes  may 
have  a  twofold  origin — physiological  and  pathological.  Under 
ordinary  circumstances  the  phenomenon  is  certainly  associated 
with  sleep,  but  just  as  certainly  in  pathological  conditions  this  is 
not  always  the  case.  The  origin  of  the  symptom  is  often  in  such 
lesions  as  interfere  with  the  harmonious  successive  and  gradual 
working  of  the  different  parts  of  the  respiratory  centre.  By  means 
of  such  disturbances  of  particular  phases  of  its  activity,  its  functions 
are  no  longer  continuous  but  periodic. 

Storch^  records  intermittent  respiration,  perhaps  not  a  typical 
instance  of  Cheyne-Stokes  breathing,  in  a  horse,  18  years  old, 
which  died  from  what  is  known  in  Germany  and  Austria  as 
"  Pferdetyphus,"  an  affection  characterized  by  general  extravasation 
and  exudation.  In  this  case  there  was  much  extravasation  into 
the  mucous  and  serous  membranes. 

The  author  discusses  several  of  the  well-known  explanations  of 
Cheyne-Stokes  respiration,  and  states  that  he  considers  Eosenbach's 
theory  as  the  most  probable. 

Fano^  criticises  Mosso's  work,  and  points  out  that  the  views 
therein  expressed  on  the  automatism  of  the  respiratory  centre  are 
essentially  the  same  as  those  advanced  by  Luciani  and  himself.  He 
has  some  hesitation,  however,  in  regard  to  Mosso's  sleep  hypothesis. 

Fenoglio,*  to  test  the  accuracy  of  Mosso's  observation  that  in 
sleep  the  respiration  may  become  periodic,  watched  the  sleep  of  a 
hundred  old  men,  whose  ages  averaged  75  years,  and  an  equal 
number  of  old  women  averaging  70  years  of  age.  He  found 
periodic  breathing  in  six  men,  but  not  in  any  of  the  women.  In 
two  cases,  where  long  pauses  had  been  seen,  post-mortem  examina- 
tions were  obtained.     In  one  case  there  were  no  changes  in  the 

^  Revista  clinica  di  Bologna,  serie  terza,  tomo  v.  p.  161,  1885. 

2  Revue  filr  Thierheilkunde  und  Thierzuchty  viii.  Band,  S.  145  u.  165,  1885. 

3  Lo  Sperimentale,  tomo  Ivii.  p.  1,  1886. 
*  Ibid.,  tomo  Ivii.  p.  113,  1886. 


1112  DR   G.   A.   GIBSON   ON   THE  [jUNE 

brain  ;  in  the  other  there  were  chronic  meningeal  lesions,  but  the 
medulla  was  healthy.  Fenoglio  is  inclined  to  attribute  the  pheno- 
menon to  excessive  fatigue  and  great  need  for  rest,  which  speak 
of  exhaustion  of  the  system  through  severe  disease. 

Poole ^  has  enunciated  some  views  on  the  subject  which  are 
singular  in  themselves,  and  are  probably  based  upon  an  imperfect 
appreciation  of  physiological  facts.  Stating  that  all  the  theories 
previously  brought  forward  are  based  upon  the  assumption  that 
impure  venous  blood  acts  as  a  stimulus  to  the  nerve  centres,  he 
asserts  that  venous  blood  is  a  depressant  of  nerve  function.  He 
grants  that  for  the  appearance  of  Cheyne-Stokes  respiration  there 
must  be  a  condition  of  partial  paralysis  of  the  respiratory  centre, 
and  that  the  blood  is  imperfectly  arterialized.  The  heart,  however, 
continuing  to  beat  sends  some  blood  through  the  lungs  during  the 
pause,  which  becomes  oxygenated  by  means  of  tlie  residual  air ; 
this  reaching  the  nerve  centres  revives  them  and  causes  a  dilata- 
tion of  the  arterioles,  which  occurs  simultaneously  with  the 
laboured  breathing.  The  inrush  of  blood  into  the  lungs  is  too  great 
to  allow  of  proper  oxygenation,  and  the  imperfectly  arterialized 
blood  depresses  the  medullary  centres,  whence  a  pause  again  takes 
place. 

Bordoni^  begins  his  inaugural  dissertation  on  this  subject  by  a 
historical  retrospect,  and  mentions  that  he  has  seen  the  symptom 
on  six  occasions — twice  in  fatty  heart  with  pneumonia ;  once  in 
inflammation  of  the  endo-myo-pericardium  (referred  to  at  p.  1106) ; 
twice  in  cerebral  apoplexy ;  and  once  in  fracture  of  tlie  temporal 
bone  (referred  to  at  p.  1109).  This  is  followed  by  a  consideration  of 
the  conditions  present  in  the  medulla  oblongata,  and  of  the  cir- 
cumstances, physiological  and  pathological,  under  which  Cheyne- 
Stokes  breathing  may  appear.  The  author  then  considers  the 
phenomena  presented  by  the  symptom  and  the  various  changes 
which  are  associated  with  it,  entering  into  a  masterly  examination 
of  these  appearances  and  of  the  conditions  giving  rise  to  them. 

He  then  proceeds  to  discuss  the  occurrence  of  the  symptom  in 
lower  animals  and  its  production  by  various  agencies,  and  describes 
some  experiments  performed  by  himself,  whereby  he  found  that  in 
frogs  periodic  breathing  could  be  caused  by  digitalin,  scillain,  and 
gelsemine. 

The  second  part  of  his  thesis  is  devoted  by  the  author  to  an 
able  criticism  of  the  various  theories  which  have  been  advanced 
by  previous  writers,  and  this  leads  him  to  support  the  views  of 
Luciani : — Firstly,  that  the  normal  type  of  respiration  is  the  result 
of  continuous  irritability  of  the  respiratory  centre  and  of  the  influ- 
ence of  varying  stimuli ;  and,  secondly,  that  Cheyne-Stokes  respira- 
tion and  all  forms  of  periodic  breathing  depend  upon  variations  of 

1  The  Canada  Lancet,  vol.  xviii.  p.  197,  1886. 

'  Sul  Tipo  Respiratorio  di  Cheyne  e  Stokes,  osservazione  e  ricerche  sperimentali, 
Siena,  1886. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   KESPIRATION.  1113 

this  irritability,  having  their  origin  in  transitory  or  permanent 
changes  in  the  respiratory  centre. 

Piaggio/  whose  inaugural  dissertation  on  this  subject  has  already 
been  noticed,  again  deals  with  the  subject  in  an  interesting  paper. 
This  communication  begins  with  a  review  of  Langendorff's 
observations  and  a  criticism  of  his  views.  The  author  then  calls 
attention  to  the  phenomena  which  accompany  the  respiratory 
symptom.  He  is  of  opinion,  as  previously  stated  in  his  thesis, 
that  an  asphyxia  or  insufficient  access  of  oxygen  to  the  tissues  is 
the  determining  cause  of  the  phenomena,  and  he  regards  the  forced 
respiration  of  the  period  of  breathing  as  a  false  dyspnoea.  He 
does  not  think  that  Langendorff  has  penetrated  into  the  secrets  of 
the  internal  mechanism  which  account  for  the  symptoms.  He 
holds  that  his  interpretation  implies  an  idea  of  resistance  to  the 
passage  of  nerve  force,  thus  determining  periodic  discharges,  and 
cannot  admit  it. 

Unaware  of  the  observations  of  earlier  writers  on  the  connexion 
between  the  respiratory  and  pupillary  phenomena,  Robertson^ 
brought  forward  the  rhythmic  contraction  of  the  pupils  in  Cheyne- 
Stokes  respiration,  as  seen  in  two  patients  who  had  been  under  his 
care.  He  gives  a  full  and  clear  description  of  the  eye  symptoms 
as  well  as  of  the  alternate  contractions  and  relaxations  of  the 
muscles  of  the  limbs,  which  were  especially  well  marked  in  one  of 
his  cases. 

Being  unacquainted  at  the  time  with  the  observations  of  Rosen- 
bach  and  others  who  have  disproved  the  statement  that  amyl 
nitrite  invariably  produces  a  disappearance  of  the  symptom,  the 
opportunity  afforded  by  a  case  of  chronic  renal  disease  in  a 
woman  aged  60,  accompanied  by  Cheyne-Stokes  respiration, 
was  employed  by  me^  as  a  means  of  testing  the  efficiency  of 
that  remedy.  In  this  case  the  drug,  although  effecting  its 
usual  changes  as  regards  the  circulation,  failed  to  produce  any 
modifications  in  the  respiratory  rhythm.  The  injection  of  nitrate 
of  pilocarpine  was  in  this  case  resorted  to  for  the  relief  of  the 
respiratory  and  other  symptoms.  It  was  followed  by  a  disappear- 
ance of  the  pauses,  which  only  continued  for  about  a  minute.  It 
seemed  to  me,  as  stated  in  the  paper  referred  to,  that  this  brief 
disappearance  of  the  periodic  cessations  of  breathing  was  caused 
by  the  shock  of  the  injection,  and  it  also  appeared  extremely  prob- 
able that  in  cases  where  nitrite  of  amyl  had  been  found  efficacious, 
its  action  was  to  be  regarded  as  due  to  a  stimulant  effect  upon  the 
respiratory  centre.  It  has  since  come  to  my  knowledge  that  this 
view,  as  mentioned  in  an  earlier  part  of  this  contribution,  has  also 
been  previously  advanced. 

1  Le  Progres  medical,  xiv.  ann^e,  ii.  serie,  tome  iv.,  deuxifeme  aemestre,  p.  690. 
1886. 

2  The  Lancet,  vol.  ii.  for  1886,  p.  1016. 

^  The  Practitioner,  vol.  xxxviii.,  p.  85,  1887. 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    XII.  7   B 


1114  DR   G.   A.    GIBSON   ON   THE  [jUNll 

Finlayson^  prefaces  some  interesting  remarks,  made  at  the 
Medico- Chirurgical  Society  of  Glasgow,  on  the  state  of  the  pupil  in 
Cheyne-Stokes  respiration,  by  expressing  his  opinion  that  the  dis- 
tinction drawn  by  several  writers  between  Cheyne-Stokes  breath- 
ing and  the  less  regularly  intermittent  respiration  of  cerebral 
disorders  is  one  of  degree  only,  and  that  there  is  a  perfect  gradation 
between  the  two  varieties.  The  author  enters  upon  the  well- 
known  phenomena  of  the  pupils  which  usually  accompany  Cheyne- 
Stokes  breathing,  and  states  that  although  the  reversed  relation- 
ship has  been  described,  i.e.,  a  dilatation  of  the  pupil  during  the 
pause  and  a  contraction  in  the  period  of  breathing,  he  has  never 
himself  seen  it. 

The  interest  of  Finlayson's  communication,  however,  lies  chiefly 
in  this,  that  he  for  the  first  time  describes  a  rhythmical  enlarge- 
ment of  the  pupil  with  each  individual  inspiration,  and  a  subse- 
quent narrowing  with  the  succeeding  expiration.  He  is  inclined 
to  regard  this  phenomenon  as  being  possibly  but  an  exaggeration 
of  a  physiological  variation  which  has  been  alleged  to  occur  in  the 
pupil  with  each  respiration. 

In  the  discussion  which  followed  the  reading  of  Finlayson's 
paper,  M'Vail^  lays  stress  upon  the  reversal  of  the  pupillary 
phenomena  to  be  seen  in  some  cases  of  Cheyne-Stokes  breathing. 

Gowers,^  after  briefly  describing  the  phenomenon  and  shortly 
mentioning  some  of  the  explanations  advanced  to  account  for  it, 
makes  the  following  remarks : — "  On  the  whole  it  may  be  said  that, 
unless  the  simple  rhythmical  tendency  of  the  depressed  centre  is 
adequate  to  produce  the  phenomena,  they  can  be  best  explained 
by  the  assumption  that  this  rhythmical  tendency  is  modified  by 
some  other  periodical  influence,  of  which  vaso-motor  spasm  is  the 
only  one  which,  according  to  our  present  knowledge,  can  be  con- 
ceived as  acting  and  adequate.  The  gradual  onset  of  the  respira- 
tions may  be  due  to  the  fact  that  the  vaso-motor  dilatation  exceeds 
the  normal  (as  it  often  does  after  contraction),  and  thus  the 
quantity  of  blood  reaching  the  respiratory  centre  lessens  the 
stimulating  influence  of  its  quality." 

Vierordt*  allows  that  the  phenomenon  undoubtedly  depends 
upon  a  disturbance  of  the  functions  of  the  respiratory  centre  in 
the  medulla  oblongata,  but  is  of  opinion  that  all  more  explicit 
theories  are  unavailing  to  explain  it.  He  thinks  that  a  simple 
diminution  of  the  excitability  of  the  cells  of  the  centre  from  the 
presence  of  venous  blood  could  only  give  rise  to  infrequent  and 
possibly  irregular  respiration,  which  might  either  be  deep  or  shallow, 
and  that  to  ascribe  a  different  degree  of  excitability  to  particular 

^  Glasgow  Medical  Journal^  fourth,  series,  vol.  xxviii.  p.  221,  1887. 

2  Ihid.  p.  224. 

3  A  Manual  of  Diseases  of  the  Nervous  System,  vol.  ii.  p.  118.    London,  1888. 
*  Diagnostik  der  inneren  Krankheiten  auf  Grund  der  heutigen  Untersuchungs- 

Methoden,  S.  64.     Leipzig,  1888. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION.  1115 

cells  or  groups  of  cells  is  at  least  a  refinement — in  short,  that  we 
are  in  want  of  a  distinct  explanation  of  the  phenomenon. 

Marckvvald^  devotes  a  section  of  his  admirable  work  on  the 
respiration  to  the  subject  of  periodic  breathing.  He  shows  that 
the  medulla  may  be  divided  in  the  region  of  the  acoustic  tubercles 
without  inducing  any  alteration  in  respiratory  rhythm,  but  that  if 
the  section  is  made  lower  down  at  the  level  of  the  alse  cinereee  the 
breathing  at  once  becomes  periodic.  Periodic  respiration  may 
follow  the  higher  section  if  a  blood-clot  has  caused  pressure  upon 
the  respiratory  centre,  or  if  the  respiratory  centre  has  been  exposed 
to  the  air.  During  periodic  respiration  he  finds  that  the  excita- 
bility of  the  centre  has  not  in  any  way  suffered,  for  stimuli  to  the 
skin  during  the  pauses  are  immediately  followed  by  movements  of 
respiration.  Marckwald  was  never  able  to  produce  periodic 
breathing  by  means  of  pressure  upon  the  medulla  in  the  region  of 
the  alse  cinereae,  the  result  of  which  was  a  cessation  of  respiration. 
Section  below  the  upper  level  of  the  alae  cinerese  was  always 
followed  by  destruction  of  the  respiration,  which  could  not  be 
restored  by  any  means.  The  author  has  never  seen  an  ascending 
and  descending  series  of  respirations  produced  artificially,  only  a 
descending  group,  but  he  recalls  the  fact  that  in  Cheyne-Stokes 
breathing  the  groups  are  sometimes  also  of  this  latter  kind  alone. 
He  is  of  opinion  that  periodic  breathing  only  takes  place  when  at 
least  a  part  of  the  higher  brain  tracts  has  ceased  to  act  and  has 
lost  its  influence  upon  the  respiratory  centre,  which  he  believes  to 
accord  well  with  the  mode  of  occurrence  of  Cheyne-Stokes 
breathing,  as,  for  example,  in  sleep  and  hibernation ;  after  the  use 
of  certain  drugs,  wbich  paralyse  the  upper  nervous  centres,  or 
lessen  the  circulatory  supply  to  the  brain;  and  from  various 
experiments  upon  the  nervous  and  circulatory  systems.  In  this 
connexion  Marckwald  mentions  a  case  of  hemiplegia  which  he 
observed  under  the  care  of  Lichtheim,  where  only  the  descending 
series  of  Cheyne-Stokes  breathing  was  present.  The  patient  in 
this  case  was  able  to  modify  the  breathing,  but  when  left  to  herself 
it  was  always  periodic.  In  this  case  one-sided  deficiency  of  the 
upper  brain  tracts  was  sufficient  to  produce  Cheyne-Stokes 
breathing. 

Marckwald  points  out  that  after  the  production  of  periodic 
breathing  experimentally,  section  of  the  vagi  causes  it  at  once  to 
disappear,  and  he  is  therefore  of  opinion  that  for  the  appearance  of 
periodic  breathing  it  is  necessary  to  have  the  peripheral  branches 
of  the  vagi  in  connexion  with  the  respiratory  centre.  As  stimuli 
during  the  pause  produce  respirations,  he  cannot  admit  that  a 

^  The  Movements  of  Respiration  and  their  Innervation  in  the  Rabbit.  Translated 
by  Thomas  Arthur  Haig,  student  of  medicine,  University  of  Glasgow,  and 
revised  by  the  Author,  with  an  Introductory  Note  by  John  G.  M'Kendrick, 
M.D.,  LL.D.,  F.R.S.,  Professor  of  Physiology,  University  of  Glasgow,  p.  45. 
London,  1888. 


1116  DR   G.   A.   GIBSON   ON   THE  [JUNE 

diminished  excitability  of  the  respiratory  centre  is  the  cause  of  the 
phenomenon. 

Descourtis^  describes  a  case  of  Cheyne-Stokes  breathing  in  a 
man,  aged  68,  suffering  from  general  paralysis.  In  this  instance 
the  pulse,  as  ascertained  by  the  sphygmograph,  remained  constant 
in  its  characters  throughout  the  varying  phases  of  the  respiration. 

In  a  short  abstract  by  Smart ^  of  a  paper  read  by  him  at  the 
Medico- Chirurgical  Society  of  Edinburgh,  cerebral  respiration  and 
Cheyne-Stokes  respiration  are  grouped  together  as  "  Multiple  Com- 
plex Eespiratory  Neuroses,"  but  the  author  insists  on  their  inde- 
pendence of  each  other. 

A  communication  was  recently  made  by  me^  with  the  view  of 
showing  that,  whatever  may  be  the  nature  of  the  condition  under- 
lying the  associated  symptoms  of  Cheyne-Stokes  respiration,  it 
may  produce  the  effects  which  depend  on  it  by  affecting  the  lower 
centres  in  the  first  place,  and  spreading  upwards  to  the  higher,  or 
by  acting  upon  the  higher  first,  and  afterwards  invading  the  lower 
centres.  This  was  illustrated  by  reference  to  the  presence  of 
Cheyne-Stokes  breathing  in  a  case  of  pneumonia,  without  any 
changes  in  the  pulse,  pupil,  mind,  or  muscles ;  to  its  appearance 
in  a  case  of  cardiac  failure,  in  which  it  was  accompanied  by 
circulatory,  pupillary,  and  mental  symptoms ;  and  to  its  occur- 
rence in  cases  of  uraemia  in  association  with  periodic  alterations 
in  the  circulatory,  visual,  psychical,  and  muscular  condition. 
These  different  classes  of  cases  were  regarded  as  presenting  a 
regular  series  of  symptoms,  commencing  with  those  showing 
consequences  depending  upon  some  affection  of  the  respiratory 
centre  alone,  and  passing  through  others  having  a  progressive 
tendency  to  involve  different  centres.  The  paper  next  attempted 
to  show  that  the  periodic  changes  produced  by  alterations  of  the 
centres  may  commence  in,  and  be  limited  to,  those  which  are  not 
concerned  in  vital  phenomena.  The  case  of  a  child  suffering  from 
what  clearly  seemed  to  be  tubercular  meningitis,  but  which,  owing 
to  the  recovery  of  the  patient,  may  appear  to  have  been  possibly 
an  error  in  diagnosis,  was  taken  to  illustrate  my  meaning.  The 
patient  was  a  little  girl,  aged  three  years,  presenting  all  the 
symptoms  of  subacute  tubercular  meningitis.  During  the  course 
of  the  disease,  when  watching  her  carefully  one  day,  a  periodic 
closure  of  the  eyelids  attracted  my  attention,  and  on  further 
observation  it  was  easy  to  determine  that  along  with  this  closure 
of  the  lids  there  was  a  simultaneous  contraction  of  the  pupils,  and 
a  state  of  complete  unconsciousness.  This  condition  remained  for 
several  seconds,  the  eyelids  were  then  raised,  the  pupils  dilated, 
consciousness  returned,  and  the  child  raised  her  head  to  look 
about.      The   conscious   state  was   present   for   some    time,  how 

1  VEncephale,  vol.  viii.  p.  431,  1888. 

2  The  Edinburgh  Medical  Journal,  vol.  xxxiv.  p.  529,  1888. 
'  The  Birmingham  Medical  Review^  vol.  xxv.  p.  30,  1889. 


1889.]  PHENOMENA   IN   CHEYNE-STOKES   KESPIRATION.  1117 

long  it  is  not  possible  for  me  to  say,  as  it  did  not  occur  to  me  to 
notice  the  interval,  and  was  in  its  turn  followed  by  the  uncon- 
scious condition.  In  this  case  there  was  never,  so  far  as  my 
observation  went,  any  tendency  to  a  periodic  change  in  the  rhythm 
of  the  breathing.  It  seemed  to  me  that  such  a  phenomenon  can 
only  be  regarded  as  analogous  in  every  way  to  intermittent  re- 
spiration, and,  if  this  be  granted,  it  follows  that  my  contention  is 
to  be  regarded  as  highly  probable. 

This  brings  us  to  the  end  of  the  examination  of  the  facts  and 
views  embodied  in  the  different  works  on  the  subject.  In  addition 
to  the  authors  who  have  been  mentioned,  reference  might  have 
been  made  to  many  others  who  incidentally  touch  upon  the 
subject,  but,  in  so  far  as  my  acquaintance  with  the  literature  is 
concerned,  these  authors  neither  add  anything  to  the  store  of  facts 
nor  throw  any  light  upon  their  explanation.  It  is,  in  consequence, 
unnecessary  to  devote  time  and  space  to  them. 

Before  leaving  this  division  of  the  subject,  a  few  remarks  must 
be  made  upon  three  unpublished  observations  which  have  been 
communicated  to  me. 

Dr  Muirhead,  of  Edinburgh,  informs  me  of  an  elderly  gentle- 
man, who  for  many  years  during  his  daily  sleep  after  dinner 
breathed  in  the  characteristic  Cheyne-Stokes  type. 

Dr  Edes,  of  Washington,  writes  to  me  with  regard  to  a  lady 
whose  breathing  has  for  many  years  been  periodic  or  cyclical,  as  he 
prefers  to  term  it,  during  sleep.  A  most  interesting  fact  is  that 
this  lady  tells  him  the  phenomenon  had  been  noticed  by  her 
mother  as  present  in  herself  and  her  sister  from  childhood. 

Finally,  Dr  Tuke  has  placed  the  following  interesting  communi- 
cation in  my  hands : — 

*'  Balgreen, 
"Edinburgh,  2Sth  February  1889. 

*'  Dear  Gibson, — Knowing  you  are  specially  interested  in  *  Cheyne-Stokes 
breathing,'  I  send  you  a  short  report  of  a  case  which  came  under  my  observa- 
tion last  Saturday.  On  that  afternoon  my  two  favourite  Dandie  Dinmonts 
were  poisoned  by  strychnine,  which  had  been  laid  down  for  rats  in  the  stable  ; 
the  one  fatally — dying  in  opisthotonus — the  other  recovering  after  fifteen  hours 
of  suffering.  During  all  that  time  he  was  under  my  most  careful  observation. 
After  five  violent  spasms  (opisthotonus)  I  bolstered  the  dog  in  such  a  way 
that  he  could  not  move,  as  the  slightest  stimulus  induced  the  attacks.  By 
this  means  the  general  spasms  were  averted,  and  only  occasional  jerks  were 
observed.  But  fifteen  minutes  after  he  was  thus  restrained  well  marked 
Cheyne-Stokes  breathing  set  in — the  number  of  respirations  was  about  25, 
and  the  interval  was  somewhat  longer  than  I  have  generally  noticed  in  the 
human  subject.  The  pupils  were  fully  dilated  during  the  breathing,  the  iris 
contracting  slightly  during  the  interval.  So  far  as  I  could  judge,  the  dog  was 
conscious  all  the  time,  often  trying  to  wag  his  tail.  The  rate  of  the  heart  was 
120,  and  its  action  was  regular,  which  is  curious,  as,  imder  ordinary  circum- 
stances, this  dog's  heart,  like  that  of  most  dogs,  is  very  irregular,  and  some- 
times intermitting.  Its  usual  rate  is  104.  The  femoral  pulse  was  full  and 
steady.  When  violent  spasms  showed  themselves,  the  Cheyne-Stokes  breathing 
ceased.  I  kept  my  hand  slightly  pressed  on  the  ribs  ;  when  doing  so  the 
breathing  never  reached  dyspncea,  but  when  the  pressure  was  removed  the 


1118  PHENOMENA   IN   CHEYNE-STOKES   RESPIRATION,  [jUNE 

symptom  tended  to  show  itself.  After  thirteen  hours  all  the  symptoms 
disappeared — the  Cheyne-Stokes  breathing  gradually  growing  less  pronounced 
— except  stiffness  of  the  hind  legs. — I  am,  yours  sincerely, 

John  Batty  Tuke." 

So  far  as  my  knowledge  goes,  Cheyne-Stokes  respiration  has  not 
been  observed  as  a  consequence  of  the  action  of  strychnine  by  any 
of  the  authors  who  have  devoted  attention  to  the  subject. 

{To  be  continued.) 


CLINICAL  REPORT  OF  CASE  AT  EDINBURGH  ROYAL 
INFIRMARY. 

Under  the  care  of  Dr  Affleck,  and  reported  by  J.  Christian  Simpson,  M.B. 
Case  op  Reflex  Spastic  Paraplegia  which  Eecovered 

AFTER   THE   REPLACEMENT   OF   A   ReTROVERTED    UtERUS. 

This  case,  which  is  subsequently  given,  was  one  which  was  in 
"Ward  XXX.,  Royal  Infirmary,  under  the  care  of  Dr  Affleck  when  I 
was  House  Physician,  and  it  is  through  his  kindness  that  I  am 
enabled  to  report  it 

The  subject  of  paraplegia,  either  paralytic  or  spasmodic,  due  to 
hysteria  or  some  reflex  irritation,  has  been  one  about  which  there  is 
a  great  variety  of  opinion  and  room  for  speculation.  The  earliest 
advocate  for  the  purely  reflex  theory  was  Mr  Stanley,  who,  in 
1833,  referred  such  symptoms  to  ''  irritation  propagated  through 
the  sentient  nerves  to  the  spinal  cord,  whence  the  impression  was 
transmitted  through  both  motor  and  sentient  spinal  nerves,  occa- 
sioning an  impairment  both  of  sensation  and  the  power  of  motion." 
Later  on,  in  1860,  Brown-Sequard  published  the  theory  of  visceral 
irritation  causing  a  reflex  spasm  in  the  bloodvessels  of  the  cord, 
thus  impairing  its  nutrition  and  functions.  Gull  disproved  this, 
and  the  "  exhaustion  "  theory  of  Jaccoud  was  also  discarded.  In 
1869  Lewisson  made  a  series  of  experiments  which  showed  that 
paralysis  of  the  lov\'er  limbs  followed  forcible  squeezing  of  a  rabbit's 
kidneys,  uterus,  etc.,  and  this  paralysis  passed  off"  more  or  less 
abruptly  when  the  pressure  was  released.  These  experiments,  and 
a  few  recorded  cases — such  as  Hammond's  case  of  paralysis  from 
worms,  which  disappeared  when  the  worms  were  discharged,  and 
some  cases  of  urinary  paraplegia,  either  from  stricture,  as  in  Grave's 
case,  or  the  more  common  one  of  phymosis — seem  to  prove  that 
peripheral  irritation,  when  propagated  to  the  cord,  can  exert  an 
inhibitory  influence,  though  the  exact  mechanism  has  not  yet  been 
ascertained. 

The  ascending  neuritis  theory  of  Leyden  may  explain  cases 
which  do  not  recover,  and  in  these  organic  lesion  is  usually  found 
in  the  cord,  but  in  many  cases  the  recovery  and  the  symptoms  do 
not  appear  to  correspond  to  the  resolution  of  a  neuritis  or  its 
results. 


1889.]  CLINICAL   REPORT   OF   CASE   BY   DR   AFFLECK.  1119 

Upon  the  whole,  the  present  feeling  is  that  reflex  paraplegia  is  not 
an  entity,  but  rather  one  of  the  many  phenomena  for  which  hysteria  is 
made  responsible.  Fagge  confesses  that  he  has  never  yet  had  under 
his  care  a  patient  who  appeared  to  him  to  be  suffering  from  reflex 
paraplegia,  though  he  gives  a  chapter  on  this  affection  with  authentic 
cases  in  his  Treatise  on  Medicine.  G-owers,  in  his  latest  work  on 
the  nervous  system,  mentions  some  cases  of  a  similar  nature  under 
the  heading  of  "  Functional  and  Nutritional  Diseases  of  the  Cord," 
but  treats  fully  of  such  spasmodic  or  paralytic  affections  under  the 
subject  of  hysteria.  Hysterical  contractures  are  most  frequent  in 
the  muscles  of  mastication  and  of  the  arm  and  leg.  The  arm  is  in 
the  flexed  position,  but  the  leg  is  usually  in  one  of  extension  with 
the  foot  inverted  and  toes  flexed.  This  condition  of  the  legs  is 
much  more  rare  than  in  the  arms,  and  the  contracture  is  apt  to 
appear  and  disappear  suddenly  under  emotion  or  faradisation. 

The  following  case  does  not  correspond  to  any  of  these  in  many 
particulars,  and  it  is  for  this  reason,  as  well  as  on  account  of  its 
rarity,  that  I  venture  to  record  it. 

Case  of  Keflex  Spastic  Paraplegia. 

Mrs  M.,  aged  32,  from  Shetland,  was  admitted  on  16th  November 
1887,  complaining  of  pains  in  the  loins,  lower  extremities,  and  knees, 
inability  to  move  the  lower  limbs  on  account  of  rigidity,  and  fre- 
quent twitchings. 

Duration  of  Illness. — Five  months. 

Family  historij  unimportant,  except  that  her  mother  died  of 
apoplexy. 

Personal  history  is  good. 

Four  years  ago,  after  a  confinement,  she  seems  to  have  suffered 
from  some  slight  puerperal  absorption,  but  she  recovered  perfectly. 

Present  Illness. — Ten  months  ago,  when  pregnant,  she  fell  and 
hurt  her  abdomen,  being  laid  up  for  some  time,  but  this  does  not 
appear  to  have  influenced  her  labour,  which  happened  seven  months 
ago.  Two  months  after  this  she  began  to  have  down-bearing  pains, 
and  she  felt  weakness  of  the  loins  and  lower  limbs.  This  was  fol- 
lowed by  shooting  pains  in  these  parts,  also  sensations  of  heat  and 
cold,  and  some  numbness.  Two  months  ago  there  occurred  severe 
cramps,  and  spastic  rigidity  gradually  developed,  so  that  she  had 
to  lie  up,  as  any  attempt  to  walk  resulted  in  increased  rigidity  and 
locking  of  the  knees.  There  was  a  feeling  of  a  tight  girdle  round 
the  loins  and  legs.  Bowels  irregular ;  and  there  was  occasional 
difficulty  in  the  first  stage  of  micturition.  On  admission  patient 
was  evidently  a  strong,  healthy,  muscular  woman,  but  she  was 
totally  unable  to  use  her  lower  extremities,  which  were  absolutely 
rigid  in  the  extended  position.  The  alimentary,  circulatory,  respira- 
tory, integumentary,  and  urinary  systems  were  normal. 

BeprodiLctive    System. — Catamenia    regular,    but    scanty.      On 


1120  CLINICAL   REPORT   OF   CASE   BY   DR   AFFLECK.  [jUNE 

vaginal  examination  the  uterus  was  found  to  be  subinvoluted  and 
retro  versed. 

Nervous  System. — Subjective  sensory  phenomena. — Pain  in  loins 
and  legs.  Burning  pain  on  inner  side  of  knees.  Tingling  in  both 
feet,  and  formication  in  feet  and  toes.  No  numbness.  Girdle  pain 
below  left  knee. 

Sensory  Functions. — Some  anaesthesia  in  both  legs  below  the 
knee,  especially  the  right  one.  Localization  fairly  accurate ;  no 
delay  in  transmission.  Sense  of  tickling  and  pricking  normal. 
Sensations  as  to  heat  and  cold  imperfect. 

Superficial  Reilexes. — Plantar  reflex  abolished,  and  no  epigastric 
nor  abdominal  reflexes. 

Deep  Befiexes. — Patellar  tendon  reflex  is  much  exaggerated,  and 
the  leg  is  thrown  into  a  state  of  clonic  spasm.  This  also  occurs  on 
tapping  the  extensor  cruris  muscles.  The  degree  is  less  on  the 
left  side  in  both  instances.  Ankle  clonus,  which  is  carried  on  for 
several  minutes  at  a  time,  at  the  rate  of  132  per  minute,  is  readily 
produced  on  both  sides,  specially  on  the  right. 

Pressure  over  the  region  of  the  anterior  crural  nerve  lessens  the 
frequency  and  duration  of  the  ankle  clonus,  and  sometimes  stops  it 
prematurely. 

Tapping  over  the  anterior  tibial  muscles  and  on  the  tibia  pro- 
duced exaggerated  movements.  Quadriceps  clonus  is  well  marked 
on  both  sides. 

The  muscles  are  slightly  atrophied,  but  have  normal  qualitative 
electric  reaction.  Abnormal  subjective  sensations  are  absent  in  the 
arms,  as  are  also  abnormal  sensory  functions.  Deep  reflexes  normal 
in  arms. 

There  is  a  sensation  of  girdle  pain  in  the  iliac  regions,  and  the 
sensation  of  pain  is  more  marked  in  the  abdomen  than  in  the  legs. 

Sensation  over  chest  normal.  Trophic  and  vaso-motor  functions 
are  normal.  Eye  reflexes  normal.  Organic  reflexes  normal,  except 
occasional  slight  retention  of  urine.  Cerebral  and  mental  functions 
normal.     Cranium  and  spine  normal ;  hot  sponge  test  absent. 

Although  the  diagnosis  of  reflex  spastic  paralysis  was  soon 
arrived  at,  and  the  cause  recognised,  various  medicines  and  other 
treatments  were  applied  in  the  first  instance.  Thus,  bromide  and 
iodide  of  potash  with  cannabis  indica  were  given,  syrup  of  hypo- 
phosphites,  ammoniated  tincture  of  valerian,  all  witliout  effect,  for 
on  10th  December  she  was  hopelessly  unable  to  walk  on  account  of 
the  adductor  spasm. 

On  12th  Dec.  the  Button  cautery  was  freely  applied  to  both 
limbs,  but  also  with  no  ultimate  benefit. 

20th  Dec. — Battery  been  freely  used,  and,  if  anything,  slightly 
less  spasm  in  the  left  leg,  but  immaterial. 

In  the  end  of  December  she  was  seen  by  Dr  Halliday  Groom, 
who  confirmed  the  diagnosis  of  the  uterine  displacement,  and 
rectified  it  with  a  pessary.     From  this  date  she  began  to  improve. 


1889.]  CLINICAL  EEPORT   OF   CASE  BY  DR   AFFLECK.  1121 

16th  Jan. — Burning  pain  in  knees  present ;  girdle  pain  some- 
what better ;  sense  of  touch  much  better,  especially  in  left  leg  ; 
ankle  clonus  in  both  limbs  is  greatly  diminished,  and  she  has 
more  control  over  it — stopping  in  less  than  half  a  minute. 

She  cannot  yet  move  the  right  leg  except  to  a  small  extent,  but 
the  left  leg  can  be  flexed  and  extended  with  some  ease.  When 
this  movement  is  performed,  the  knee  is  thrown  out  and  the  foot 
assumes  the  position  of  talipes-valgus.  The  muscles  of  the  anterior 
tibio-fibular  region  and  of  the  calf  respond  more  readily  to  the 
interrupted  electric  current  than  do  the  peronei — those  of  the 
right  less  readily  than  of  the  left.  Patellar  tendon  reflex  less.  In 
attempts  to  walk  she  is  able  to  bring  forward  the  left  leg.  The 
left  plantar  reflex  is  somewhat  exaggerated,  but  exceedingly  slight 
with  right  side. 

February. — When  she  stands  the  knees  do  not  now  cross,  and 
she  attempts  to  walk  when  held  up.  Is  able  to  bear  some  weight 
on  the  left  leg.  The  bearing-down  pains  are  much  better,  as 
also  the  girdle  pains.  The  peronei  muscles  are  now  able  to  be 
used,  and  prevent  the  talipes-valgus  which  was  formerly  produced. 
Formication  has  left  the  left  foot.  Anaesthesia  is  much  better,  as 
also  the  sense  of  touch,  which  is  better  on  the  inner  than  the  outer 
aspect  of  the  leg.     Plantar  reflex  of  right  foot  improving. 

\2th  March. — Patient  now  able  to  walk  up  and  down  the  ward 
with  a  stick  and  a  hand.     Has  been  put  on  physostigmine  pills. 

11  th  March. — Patient  is  so  much  better,  being  able  to  walk  with 
only  slight  assistance,  that  she  has  been  discharged  to-day. 

Remarks. — That  this  is  a  case  of  uterine  reflex  spinal  paraplegia, 
and  not  one  of  the  ordinary  hysterical  type  emanating  from  the 
cerebral  centres,  I  shall  endeavour  to  show. 

The  theory  of  direct  pressure  on  the  nerves,  which  was  advanced 
to  explain  much  less  severe  symptoms  in  uterine  displacements, 
is  not  now  generally  accepted,  as  it  is  not  a  physical  possibility 
in  many  cases.  We  have,  therefore,  to  return  to  the  sympathetic 
or  reflex  causation,  and  in  considering  this,  the  nervous  supply 
of  the  uterus  and  its  ligaments  must  be  noted.  This  is,  to  a 
large  extent,  through  the  sympathetic  system,  which  is  also 
intimately  connected  with  the  spinal  cord.  Thus  the  uterus 
derives  its  nerves  from  the  hypogastric  plexus,  which  is  in  con- 
nexion with  the  12th  dorsal,  and  1st,  2nd,  3rd,  and  4th  lumbar 
nerves,  and  also  from  the  pelvic  plexus,  which  is  in  connexion  with 
the  2nd,  3rd,  and  4th  sacral  nerves  through  the  5th  lumbar  and 
upper  three  sacral  sympathetic  ganglia. 

The  ligamenta  rotunda  derive  their  nerve  supply  from  the 
genital  branch  of  the  genito-crural  nerve,  which  is  derived  from 
the  2nd  lumbar  nerve.  Thus  there  is  a  wide  area  of  the  spinal 
cord  in  intimate  relation,  through  the  sympathetic  ganglia,  with 
the  uterus  and  its  ligaments ;   and  the  phenomena  which   were 

EDINBURGH   MED.   OOURN.,    VOL.  XXXIV. — NO.    XII.  7  0 


1122  CLINICAL  EEPOKT   OF  CASE   BY    DR   AFFLECK.  [jUNE 

present  in  this  and  other  similar  cases  can  all  be  traced  to  exactly 
this  same  region  of  the  cord. 

Given  a  retroverted  uterus,  we  have  at  first  increased  tension  on 
the  ligaments ;  and  when  we  turn  to  their  nerve  supply,  we  find 
that  it  is  in  connexion  with  the  upper  two  lumbar  nerves.  The 
symptoms  first  present  in  this  case  were  pain  and  weakness  in  the 
loins,  and  some  slight  disturbance  in  micturition.  Later  on,  as  the 
irritation  radiated  both  above  and  below  this  primary  starting-point, 
and  as  the  uterus  itself  served  as  a  focus,  we  get  symptoms  referable 
to  a  larger  area  of  the  cord.  Thus  from  the  first  lumbar  nerve  there 
is  girdle  pain  in  iliac  region ;  from  the  third  and  fourth  lumbar 
nerves  girdle  pain  round  loins  and  legs,  burning  pain  in  knee  and 
egs,  spasm  of  the  adductors,  and  increased  patellar  tendon  reflex. 
From  the  fifth  lumbar  nerve,  cramp  in  the  calf  muscles ;  from  the 
lumbo-sacral  cord  and  sciatic,  tingling  in  feet,  formication  in  toes, 
abolition  of  plantar  reflex,  and  ankle  clonus ;  from  the  third  and 
fourth  sacrals,  down-bearing  pain.  After  the  replacement  of  the 
uterus  recovery  gradually  commenced  and  progressed  slowly.  The 
down-bearing  pains  disappeared,  and  the  clonus  became  markedly 
diminished.  Certain  groups  of  muscles  were  longer  in  regaining 
their  normal  condition.  Thus  while  flexion  of  the  left  thigh  was 
performed,  involuntary  abduction  of  the  thigh  took  place,  and  a 
position  of  talipes-valgus  of  the  foot  was  assumed.  As  a  rule,  the 
left  side,  which  was  on  the  whole  less  affected,  recovered  before  the 
right.  The  patellar  tendon  reflex  and  the  ankle  clonus  became 
much  less  marked,  and  some  time  later  the  abductors  of  the  thigh 
and  the  peronei  also  became  normal,  and  no  talipes  was  produced. 
In  fact,  the  recovery  was  complete,  and  the  symptoms  as  they  dis- 
appeared closely  followed  an  order  the  reverse  of  their  appearance. 
The  chief  points  which  disagree  with  the  hysterical  theory  are  : — 

1.  The  gradual  appearance  and  development. 

2.  The  extreme  ankle  clonus,  which  was  regular,  continued  for 
some  time,  readily  and  immediately  produced. 

3.  The  success  of  the  case  after  the  replacement  of  the  uterus, 
when  other  antihysterical  treatment  had  failed. 

The  lesion  of  the  nervous  system  is  more  diflicult  to  determine,  as 
its  pathology  is  not  so  accurately  known,  especially  as  regards  the 
sympathetic  portion.  That  there  was  no  disseminated  sclerosis,  nor 
sclerosis  of  the  lateral  columns  is  probable,  and  peripheral  neuritis 
of  the  spinal  nerves  can  also  be  excluded.  The  condition  of  the 
sympathetic  ganglia  must  therefore  be  considered,  and  it  is  possible 
that  cases  such  as  this  may  be  due  to  a  degeneration  of  the  gan- 
glionic cells,  which  may  gradually  clear  up  if  the  primary  cause, 
such  as  a  retroverted  uterus,  be  early  removed.  But  in  other  cases 
this  favourable  termination  does  not  take  place,  probably  on  account 
of  more  serious  organic  lesion  having  occurred  before  treatment  of 
tlie  uterus  was  adopted. 

That  there  is  an  intimate  connexion  between  such  cases  and  a 


1889.]  CLINICAL   REPORT   OF   CASE   BY   DR   AFFLECK.  1123 

diseased  sympathetic  system  I  have  endeavoured  to  show,  by  the 
close  manner  in  which  the  organs  affected  are  related  to  the  cord 
through  the  ganglia,  and  by  the  clear  way  in  which  each  symptom 
can  be  relegated  to  its  segment  in  the  cord,  and  thence  through  the 
corresponding  sympathetic  ganglia  to  the  diseased  uterus  and  its 
ligaments. 


^stxt  ^ecouti. 


REVIEWS. 

Pulmonary  Phthisis:  its  Etiolorjy,  Pathology,  and  Treatment.  By 
Alex.  James,  M.D.,  F.KC.P.  Ed.,  Lecturer  on  the  Principles 
and  Practice  of  Medicine  in  the  School  of  Medicine,  Edinburgh  ; 
Assistant  Physician  to  the  Edinburgh  Royal  Infirmary.  Edin- 
burgh and  London :  Young  J.  Pentland :  1888. 

There  are  many  works  on  consumption,  yet  there  is  room  for 
such  a  book  as  this.  The  volume  now  lying  before  us  will 
assuredly  make  its  mark,  and  take  a  high  place  amongst  the 
various  treatises  dealing  with  this  disease.  It  is  the  work  of  a 
philosophical  physician,  viewing  his  subject  from  tlie  standpoint  of 
biological  facts,  and  seeing  it  in  the  outcome  of  definite  vital  pro- 
cesses. This  conception  runs  through  the  whole  volume,  and  gives 
it,  what  is  so  often  lacking  in  medical  works,  a  scientific  com- 
pleteness— a  singleness  of  design  and  treatment,  from  the  definition 
of  phthisis,  with  which  the  author  starts,  to  the  conclusion  of  his 
suggestions  on  treatment.  The  work  is  pervaded  by  the  tone  of 
biological  science,  and  the  notes  thus  struck  and  sustained  through- 
out the  volume  blend  as  a  well-balanced  harmony,  without  the 
jarring  of  discordant  numbers. 

"  Pulmonary  phthisis,"  says  the  author  in  approaching  the 
etiology  of  the  disease,  "  is  due  to  a  condition  of  deficient  nutrition, 
permitting  the  growth  and  reproduction  in  the  lung  tissue  of  a 
lower  form  of  organized  life."  This  definition  leads  him  to  inquire 
into  the  different  causes  which  may  produce  this  condition  of 
deficient  nutrition,  and  he  lays  before  the  reader  many  important 
facts  in  regard  to  age,  stature,  sex,  occupation,  influence  of  disease, 
conditions  of  the  chest,  effects  of  seasons,  hereditary  and  con- 
stitutional tendencies,  and  the  connexion  of  all  these  factors  with 
phthisis. 

One  of  the  most  interesting  and  original  sections  of  the  work  is 
that  in  which  the  tendency  to  tubercular  disease  at  different  ages 
in  various  organs  is  worked  out.  From  the  numerous  data  tabu- 
lated by  the  author  he  concludes  that  "  tubercular  deposit  tends  to 
occur  in  the  various  tissues  at  periods  when  the  excessive  nutritive 
power  required  for  growth  is  becoming,  or  has  become,  exhausted, 


1124  PULMONAEY   PHTHISIS.  [jUNE 

and  that,  therefore,  pulmonary  tubercle  is  specially  liable  to  occur 
about  the  twenty-fifth  or  thirtieth  years."  The  arguments  which 
support  and  oppose  this  conclusion  are  stated  with  scrupulous 
fairness,  and  their  discussion  is  marked  by  great  reasoning  power, 
which  is  also  to  be  seen  throughout  the  whole  chapters  on  etiology. 

The  author's  conclusions  regarding  the  bacillus  tuberculosis  may 
be  quoted : — 

"■  1.  That  the  bacillus  of  Koch,  introduced  into  the  tissues  of  an 
animal  in  the  method  followed  by  that  observer,  is  capable  (in 
the  case  of  almost  all  animals)  of  germinating  and  producing 
general  or  local  tubercular  disease. 

"  2.  That  this  bacillus,  as  it  may  exist  in  the  atmosphere  which 
we  inhale,  can  exercise  its  injurious  effects  on  our  lung  tissues  and 
produce  phthisis,  but  that  in  order  to  do  this  the  vitality  of  the 
tissues  must  be  below  par. 

"  3.  That  this  bacillus,  liaving  found  its  way  into  a  tissue,  joint, 
lymphatic  gland,  etc.,  may  remain  there  for  years  incapable  of  doing 
mischief  if  the  state  of  nutrition  be  good,  and  that  its  power  for  evil 
in  any  tissue  of  the  body  varies  according  to  the  amount  of  impair- 
ment of  this  state  of  nutrition. 

"  4.  That  this  bacillus  is  so  ubiquitous,  and  that  its  effects  for 
evil  are  so  dependent  on  the  state  of  nutrition  of  the  tissues,  that  in 
the  great  majority  of  cases  its  importance  as  a  factor  in  connexion 
with  the  etiology,  course,  and  treatment  of  phthisis  is  subordinate 
to  that  of  the  tissue  nutrition." 

Dividing  phthisis  into  three  types — pneumonic,  fibroid,  and 
tubercular — the  author  sees  in  each  of  them  only  the  process  in  the 
disease  which  has  taken  the  predominance,  and  he  wisely  prefaces 
his  description  of  these  forms  by  strongly  insisting  upon  the 
immense  importance  to  be  attached  to  the  recognition  of  apex 
catarrh,  so  often  the  herald  of  the  fatal  disease. 

A  great  feature  of  the  work  is  that  the  author  invariably  tries  to 
see  the  salutary  as  well  as  the  injurious  influences  of  all  the 
processes  with  which  we  have  to  deal  in  the  case  of  phthisis.  This 
method  of  viewing  the  facts  under  consideration  is  of  high  scientific 
interest,  and  gives  the  volume  an  eminently  judicial  method  of 
studying  the  disease.  It  is  to  be  found  throughout  all  the  different 
sections  of  the  book;  as  examples,  we  may  refer  to  the  diminu- 
tion of  the  stature  of  men  in  towns  as  representing  in  the  circum- 
stances a  salutary  process,  and  to  the  possibility  that  perspirations 
may  be  to  some  extent  directly  beneficial. 

Into  the  chapters  dealing  with  symptoms,  course,  and  treatment, 
time  forbids  us  to  enter ;  suffice  it  to  say  that  they  are  marked  by 
the  same  keen  spirit  of  inquiry  as  the  rest  of  the  volume. 

The  book  is  written  in  strong,  nervous  English,  characterized  by 
equal  lucidity  and  grace ;  it  therefore  goes  without  saying  that  it  is 
a  pleasure  to  read  it.  In  many  respects  it  adds  considerably  to  our 
knowledge  of  phthisis,  especially  as  regards  the  effects  of  many 


1889.]  PHYSICAL  DIAGNOSIS   OF   THE   CHEST,   ETC.  1125 

influences  at  work  in  the  causation  of  the  disease ;  and  in  keeping 
the  biological  aspect  of"  the  disease  steadily  in  view,  it  must  be 
allowed  to  have  a  real  scientific  import.  The  author  is  to  be  con- 
gratulated on  having  produced  a  work  which  will  greatly  enhance 
his  own  reputation  and  redound  to  the  honour  of  the  Edinburgh 
Medical  School. 


The  Essentials  of  Physical  Diagnosis  of  the  Chest  and  Abdomen. 
By  J.  Walker  Anderson,  M.D.,  Physician  to  the  Royal 
Infirmary,  Glasgow,  and  Lecturer  on  Medicine,  Royal  Infirmary 
Medical  School.     Glasgow  :  James  Maclehose  &  Sons :  1889. 

This  little  work  is  no  mere  compilation,  but  is  the  outcome  of 
careful  observation  by  one  who  is  himself  a  medical  teacher.  It 
bears,  as  might  be  expected,  with  great  directness  upon  the  wants 
of  the  student,  and  lays  before  him,  within  small  space,  the  most 
important  points  which  should  be  kept  in  view. 

The  influence  of  Gairdner  is  seen  throughout  the  work,  and  the 
author  in  several  places  acknowledges  this  with  the  respectful 
admiration  usually  experienced  by  those  who  have  had  the  good 
fortune  to  be  his  pupils.  It  need  hardly  be  added,  therefore,  that  the 
main  lines  of  the  book  are  thoroughly  scientific,  and  the  details  are 
set  forth  with  due  regard  to  their  relative  value.  The  book  is 
pleasantly  written,  and  may  be  recommended  to  the  student  as 
a  reliable  guide  to  the  elements  of  physical  diagnosis. 


The  Diseases  of  the  Chest.  By  Vincent  D.  Harris,  M.D.  Lond., 
F.R.C.P.,  Physician  to  the  Victoria  Park  Hospital  for  Diseases 
of  the  Chest.     London  :  J.  &  A.  Churchill :  1888. 

In  comparatively  small  compass  the  author  of  this  useful  little 
book  has  managed  to  give  excellent  descriptions  of  the  normal 
chest,  of  the  symptoms  of  disease  of  the  chest,  and  of  the  physical 
examination  of  the  chest,  along  with  a  concise  but  none  the 
less  thorough  account  of  most  diseases  to  which  the  thorax  is  liable. 
The  work  is  well  arranged,  and  contains  a  large  number  of  care- 
fully tabulated  facts  which  cannot  fail  to  be  of  great  use  to  the 
student  of  clinical  medicine.  It  is  also  for  the  most  part  well 
written,  but  there  are  a  few  passages  characterized  by  a  style  so 
involved  as  torender  their  comprehension  difficult.  For  example: — 
"  Pulmonary  valve  disease  is  so  very  rare  that  it  is  unlikely  that, 
amid  the  doubts  surrounding  the  diagnosis,  many  observations  have 
been  taken  of  the  possibility  of  tiie  disease  existing  without 
murmur,  or  of  the  murmur  or  murmurs  altering  or  disappearing, 
and  we  have  been  unable  to  find  any  remarks  on  the  subject  in  any 
of  the  standard  works  on  cardiac  affections." 

Such  a  passage  as  this  resembles  certain  forms  of  conundrum. 
It  is  only  fair  to  state  that  there  are  not  many  sentences  like  this 


1126  MEDICAL  AND   SURGICAL   MEMOIRS,   ETC.  [jUNE 

and  as  a  wliole  the  book  merits  considerable  commendation.  The 
illustrations  are  all  of  a  high  degree  of  excellence,  and  the  work 
will  be  found  to  be  of  much  utility  for  students  beginning  to  study 
clinical  medicine. 


Medical  and  Surgical  Memoirs:  containing  Investigations  on  the 
Geographical  Distribution ^  Causes,  Nature,  Relations^  and  Treat- 
ment of  various  Diseases,  1855-87.  Bv  Joseph  Jones,  M.D., 
Professor  of  Chemistry  and  Clinical  Medicine,  Tulane,  University 
of  Louisiana.  Vol.  I.,  pp.  xvii.  and  820.  New  Orleans :  1876. 
Vol.  II.,  pp.  XX.  and  1348,  16  Plates  with  75  figures,  and  140 
Engravings.     New  Orleans :  Published  by  the  Author :  1887. 

Professor  Joseph  Jones  was  a  surgeon  in  the  provisional  army 
of  the  Confederate  States,  and  subsequent  to  the  war  he  has  been 
engaged  in  professorial  work,  and  he  was  President  of  the  Board  of 
Health  of  the  State  of  Louisiana  from  1880  to  1884.  During  his 
whole  career  he  has  evidently  been  not  only  an  original  and  pains- 
taking observer,  but  a  man  who  has  sought  to  benefit  his  profession 
by  numerous  and  extensive  contributions  to  its  literature.  He 
states  in  the  preface  to  the  first  volume  now  before  us,  that  he  had 
''  no  theories  to  maintain  or  destroy,"  and  that  it  has  been  "  his 
constant  aim  to  purify  from  error  the  observations  which  he  has 
recorded,"  and  he  has  also  endeavoured  "  to  present  such  an  analysis 
of  the  labours  of  others  in  connexion  with  the  subjects  examined 
as  might  prove  of  value  to  students  and  practitioners  of  medicine." 
In  illustrating  all  important  conclusions  or  laws  in  pathology  and 
therapeutics,  he  has  in  this  volume  utilized  over  800  carefully  re- 
corded cases,  and  some  400  experiments  on  living  animals. 

We  have  only  space  to  refer  very  briefly  to  this  first  volume.  It 
comprises  an  introduction  to  the  study  of  the  nervous  system, 
investigations  on  traumatic  tetanus,  epilepsy,  paralysis,  and  cerebro- 
spinal meningitis ;  clinical  observations  on  diseases  of  the  lym- 
phatic and  circulatory  systems,  and  of  the  liver  and  kidneys ; 
investigations  and  researches  on  pneumonia;  observations  on  the 
diseases  of  the  osseous  system,  illustrated  by  800  cases  of  disease, 
400  physiological  experiments,  95  analyses  of  the  blood  in  urine, 
and  60  tables  illustrating  the  symptoms  and  mortality  of  disease 
under  different  modes  of  treatment  and  in  different  climates.  The 
volume  contains  much  valuable  information,  and  the  tables  are 
particularly  well  worth  attentive  study. 

Turning  now  to  the  second  volume,  we  find  that  it  relates  chiefly 
to  the  great  endemic  fevers  of  tropical  and  temperate  climates,  such 
as  intermittent,  remittent,  pernicious,  and  hsemorrhagic  malarial 
fevers.  It  also  contains  much  information  respecting  yellow  fever 
and  typhoid,  and  monographs  on  Oriental  leprosy,  Barbadoes  leg, 
yaws  in  the  West  Indies,  and  observations  and  researches  on 
albinism  in  the  negro  race.     Practically,  however,  the  most  valu- 


1889.]  MEDICAL  AND   SUKGICAL   MEMOIRS,   ETC.  1127 

able  chapters  are  those  which  treat  of  malaria,  which  is  most 
exhaustively  investigated  under  nine  divisions.  1.  Physical  and 
chemical  characters  of  the  blood  in  malarial  fever.  2.  Microscopical 
characters  of  the  blood  in  malarial  fever.  3.  Hsemorrhagic  malarial 
fever.  4.  Pathological  anatomy  of  malarial  fever.  5.  Phenomena 
of  fever  in  general.  6.  Cases  illustrating  the  symptoms,  history, 
pathology,  and  treatment  of  the  various  forms  of  malarial  fever.  7. 
The  prevention  of  malarial  fever.  8.  Indigenous  remedies  of  the 
United  States  of  America  which  may  be  employed  in  the  treatment 
of  the  various  forms  of  malarial  fever  as  substitutes  for  the  sulphate 
of  quinia.  9.  Practical  observations  of  the  author  on  the  treat- 
ment of  the  various  forms  of  malarial  fever,  and  the  complications 
arising  from  the  pathological  alterations  induced  by  the  malarial 
poison,  and  from  the  supervention  of  other  diseases.  To  any  one 
investigating  the  subject  of  malaria,  Professor  Jones's  work  will 
prove  a  mine  of  information.  We  know  of  no  other  single  contri- 
bution to  the  subject  where  the  same  amount  of  information  can  be 
obtained,  or  where  references  to  the  literature  on  the  subject  are 
more  numerous.  We  do  not  forget  Hirsch's  Bibliography  of 
Malaria^  but  in  the  book  before  us  one  finds  references  to  papers 
on  individual  types  of  disease.  As  an  example  of  the  care  with 
which  Professor  Jones  works,  we  may  notice  that  he  says  he  has 
searched  in  vain  for  accurate  observations  upon  the  urinary  excre- 
tion in  fevers  in  the  writings  of  246  observers,  and  he  follows  this 
statement  by  giving  a  detailed  list  of  the  authorities  whom  he  has 
consulted. 

No  one  can  read  Professor  Jones's  books  without  gleaning  a 
great  amount  of  both  theoretical  and  practical  information ;  and 
although  it  is  not  in  all  cases  possible  to  agree  with  his  opinions, 
yet  his  extensive  experience  claims  for  him  a  respectful  hearing  and 
a  careful  consideration  of  the  views  he  advances.  No  one  can  fail, 
we  think,  to  appreciate  this  work,  which  will  well  repay  a  careful 
perusal.  With  regard  to  the  illustrations,  the  plates  are  satisfactory, 
as  also  are  many  of  the  engravings.  The  second  volume  is  very 
bulky,  but  the  type  is  good. 


Reports  from  the  Laboratory  of  the  Royal  College  of  Physicians, 
Edinburgh.  By  Drs  J.  Batty  Tuke  and  G.  Sims  Woodhead. 
Edinburgh  and  London  :  Young  J.  Pentland:  1889. 

This  first  volume  of  B,eports  amply  justifies  the  expectations 
formed  of  the  important  place  which  this  Laboratory  would  occupy 
in  scientific  work. 

The  contents  are — 1.  Notes  on  the  equipment  of  the  Laboratory, 
by  G.  Sims  Woodhead.  2.  Sectional  Anatomy  of  advanced  Extra- 
uterine Gestation,  by  Drs  Hart  and  Carter.  3.  Notes  on  Mercuric 
Salts  in  Solution  as  antiseptic  Surgical  Lotions,  by  Dr  Woodhead. 
4.  The  Mechanism  of  the  Separation  of  the  Placenta  and  Membranes 


1128  -  LABORATORY   REPORTS,   ETC.  [jUNE 

during  Labour,  by  Dr  Hart.  5.  On  the  secretion  of  Lime  by 
Animals,  by  Mr  Irvine  and  Dr  Woodhead.  6.  On  a  case  of 
absence  of  the  Corpus  Callosum  in  the  Human  Brain,  by  Dr  Alex. 
Bruce.  7.  The  Air  of  Coal  Mines,  by  Dr  Naismyth.  8.  Cystic 
Disease  of  the  Ovaries,  by  Dr  Martin.  9.  Histological  Observa- 
tions on  the  Muscular  Fibre  and  Connective  Tissue  of  the  Uterus 
during  Pregnancy  and  the  Puerperium,  by  Dr  Helme.  10. 
Abstract  of  the  Result  of  an  Inquiry  into  the  Causation  of  Asiatic 
Cholera,  by  Dr  Neil  Macleod  and  Mr  W.  J.  Miller.  11.  Tabes 
Mesenterica  and  Pulmonary  Tuberculosis,  by  Dr  Woodhead. 

Many  of  the  papers  are  illustrated  by  beautiful  plates,  such  as 
Dr  Hart's,  Dr  Brace's,  Dr  Helme's,  and  Dr  Woodhead's.  In  his 
paper  on  mercuric  salts  as  antiseptics  Dr  Woodhead  points  out,  as  a 
result  of  his  researches,  that  biniodide  of  mercury  is  a  preferable 
substance  to  the  sublimate,  because  the  risks  of  poisoning  by 
absorption  are  not  so  great,  because  it  does  not  form  an  albuminate, 
because  the  mercury  from  its  solution  in  the  iodide  of  potassium  is 
not  deposited  on  the  skin  and  instruments,  and  because  the  exact 
strength  of  the  solution  is  always  known.  The  papers  are  as 
excellent  as  they  are  varied,  and  the  volume  augurs  well  for  the 
future  usefulness  of  the  Institution  as  a  nursery  and  workshop  far 
original  scientific  observation. 


A    Text-look  of  Human  Physiology.     By  Austin  Flint,  M.D., 
LL.D.     Fourth  Edition.     London :  H.  K.  Lewis  :  1888. 

We  have  to  notice  the  appearance  of  a  fourth  edition  of  this  well- 
known  American  text-book.  Thoughtful  and  carefully  written  it 
undoubtedly  is,  but  even  a  hasty  perusal  discovers  an  extraordinary 
neglect  of  the  results  of  recent  physiological  work.  If,  as  the  title- 
page  announces,  the  book  has  been  entirely  rewritten,  why  has  the 
author  not  taken  pains  to  make  it  a  safe  guide  to  the  student  of 
modern  physiology  ?  This  it  can  in  no  way  be  considered ;  and 
with  the  present  plethora  of  text-books  there  is  no  excuse  for  the 
appearance  of  another  unless  it  can  clearly  establish  its  claims.  A 
treatise,  however,  which  gives  the  composition  of  the  blood  plasma 
as  it  is  here  given  on  page  19,  enumerating  as  the  two  chief 
proteids  the  plasmine  of  Denis  and  serine,  can  hardly  be  trusted. 
The  same  table  contains  also  many  more  fallacious  statements. 

Again,  in  discussing  the  theories  of  the  process  of  coagulation,  no 
mention  is  made  of  the  valuable  work  of  Hammarsten,  or  of  the 
important  conclusions  to  which  these  observations  tend. 

One  more  instance  may  be  cited.  In  discussing  the  elimination 
of  carbonic  dioxide,  the  old  figures  of  Smith  are  given  instead  of 
the  results  of  more  recent  investigators. 

These  are  examples  selected  at  random  of  blemishes  which  are 
only  too  common  throughout  the  book,  and  which  must  very  seri- 
ously detract  from  its  utility  as  a  text-book. 


1889.]  ELEMENTS   OF   HISTOLOGY,   ETC.  1129 


Elements  of  Histology.  By  E.  Klein,  M.D.,  F.R.S.,  Lecturer  on 
General  Anatomy  and  Physiology  in  the  Medical  School  of  St 
Bartholomew's  Hospital.  New  and  Enlarged  Edition.  London: 
Cassell  &  Co.,  Lim. :  1889. 

The  student  of  physiology  will  welcome  the  appearance  of  a  new 
edition  of  Klein's  most  admirable  little  Elements  of  Histology, 
which,  in  spite  of  certain  obscurities  in  style,  has  already  proved 
itself  a  good  and  popular  guide. 

The  present  edition  contains  much  that  is  new  and  important. 
The  whole  of  that  part  dealing  with  the  structure  of  striped  muscle 
is  rewritten,  the  author  having  adopted  Rollet's  recently  published 
views.  Nuclear  division,  the  modes  of  termination  of  nerve  fibrils, 
intestinal  epithelium,  and  several  other  important  matters,  are 
treated  with  great  fulness. 

To  show  how  thoroughly  the  author  has  succeeded  in  keeping 
up  to  date,  we  may  mention  that  a  figure  from  Heidenhain's  magni- 
ficent paper  on  the  small  intestine,  which  only  appeared  towards 
the  end  of  last  year,  is  here  given.  Several  reproductions  from 
photographs  are  also  introduced  with,  we  think,  very  doubtful 
advantage.  Such  illustrations  should  not  take  the  place  of  actual 
specimens  with  the  student,  and  they  do  not  help  him  as  does  a 
diagram  to  a  clear  comprehension  of  the  arrangement  of  the  various 
tissues  in  any  organ.  To  the  trained  histologist  who  can  interpret 
them  they  are  invaluable,  but  we  fear  that  a  student  left  to  himself 
with  Fig.  44  and  the  accompanying  text  would  have  some  difficulty 
in  understanding  the  development  of  bone. 


Physiological  Diagrams  for  Use  in  Schools.     By  George  Da  vies. 
Edinburgh  :  W.  &  A.  K.  Johnston  :  1889. 

The  physiological  diagrams  drawn  by  Mr  Geo.  Davies  could 
scarcely  fail  of  their  aim.  The  teaching  of  physiology,  in  schools 
especially,  will  be  greatly  aided  by  the  use  of  the  diagrams.  The 
various  parts  of  the  body  are  sketched  out  in  clear,  distinct  lines, 
and  the  pupils  being  required  to  draw  these,  will  have  a  strong 
impression  of  the  structure  of  the  body  made  upon  their  minds. 
The  diagrams  may  be  confidently  recommended. 


On  the  Belief  of  Excessive  and  Dangerous  Tympanitis  hy  Puncture 
of  the  Abdomen.  A  Memoir.  By  John  W.  Ogle,  M.A.,  M.D. 
Oxon.,  Consulting  Physician  to  St  George's  Hospital.  London  : 
J.  &  A.  Churchill:  1888. 

This  is  a  funny  book.  The  author  became  impressed  with  the 
relief  given  in  a  case,  and  forthwith  set  himself  to  hunt  up  the 
literature  of  the  subject.     Not  only  this,  but  he  button-holed  all  the 

EDINBURGH  MED.   JOURN.,   VOL.   XXXIV. — NO.   XII.  7  D 


1130  ON   THE   RELIEF   OF   TYMPANITIS,   ETC.  [jUNE 

eminent  members  of  the  profession  in  London,  and  wrote  to  a  good 
many  in  the  provinces,  and  got  out  of  them  their  opinion  on  the 
above  procedure.  The  material  so  gleaned  is  put  into  the  hands 
of  a  publisher,  and  behold  the  present  volume.  It  is  a  novel  way 
of  making  a  book ;  and  while  the  result  is  useful  enough  in  its  way, 
it  is  one  which  we  should  advise  younger  men  not  to  imitate. 


Notes  on  Venereal  Diseases.     By  H.  de  Meric.     London : 
Henry  Renshaw :  1889. 

In  the  short  space  of  ninety-seven  pages  the  author  gives  an 
admirable  and  concise  account  of  the  chief  forms  of  venereal  dis- 
ease. This  has  been  done  by  describing  what  he  has  observed 
liimself,  and  by  being  careful  to  avoid  quotations,  a  plan  most 
highly  to  be  commended.  Mr  de  M^ric  is  what  used  to  be  called 
a  "  dualist."  He  believes  that  the  poison  of  soft  chancre  is  one 
thing  and  that  of  syphilis  another,  and  has  no  hair-splitting  theories 
which  are  now  so  common,  that  the  poison  of  soft  chancre  is  derived 
from  the  syphilitic  chancre,  but  in  some  miraculous  way  does  not 
contain  the  germ  of  syphilis. 

Of  the  three  venereal  diseases — simple  sores,  syphilis,  and  gonor- 
rhoea— he  regards  simple  sores  as  certainly  the  least  common.  This 
was  not  Ricord's  view ;  and  although  we  agree  in  Mr  de  Meric's 
estimate,  we  cannot  help  thinking  that  the  relative  frequency  of  the 
two  forms  of  sores  has  changed  somewhat  during  the  last  twenty 
years. 

When  speaking  of  the  incision  required  in  treating  a  suppurating 
bubo,  he  says  that  the  cut  should  be  made  "  in  the  same  direction 
as  the  fold  of  the  groin.  Some  surgeons  prefer  a  vertical  incision. 
This  has  the  disadvantage  of  being  necessarily  more  limited,  but 
still  may  be  said  to  possess  the  advantage  of  rendering  the  wound 
less  liable  to  gape  in  persons  who  are  obliged  to  walk  about  during 
their  treatment."  On  the  contrary,  it  is  our  experience  that  the 
vertical  incision  is  the  best,  because  the  wound  gapes  more,  and  so 
allows  the  abscess  cavity  to  heal  more  soundly  from  the  bottom,  and 
prevents,  to  a  great  degree,  the  formation  of  a  sinus. 

The  author  rightly  condemns  the  foolish  practice,  now  very 
common,  of  grounding  the  diagnosis  in  a  doubtful  case  of  tertiary 
syphilis  upon  the  effect  produced  by  iodide  of  potassium.  It  ought 
to  be  remembered  that  scrofula  as  well  as  syphilis  may  be  benefited 
by  the  drug. 

He  believes  that  mercury  is  an  antidote  to  syphilis,  by  destroying 
the  bacilli.  This  theory  is  proved  to  be  wrong  by  our  own  daily 
experience  and  by  that  of  our  medical  ancestors,  whose  heroic  doses 
of  mercury  should  have  killed  the  bacilli  without,  as  too  often  hap- 
pened, killing  the  patient.  "We  are  glad  to  find  that  a  qualification 
is  given  to  the  powers  of  mercury,  for  he  says,  "  I  do  not  believe 
that  secondary  symptoms  can  ever  be  prevented  by  treatment."     It 


1889.]  NOTES   ON  VENEREAL  DISEASES,   ETC.  1131 

is  a  satisfactory  statement  to  make,  because  true.  A  distinguished 
surgeon  in  London  had  the  audacity  recently  to  say  that,  in  the 
cases  of  syphilis  treated  from  the  beginning  by  himself,  he  would 
not  have  known  that  a  secondary  eruption  was  part  of  the  disease. 
How  completely  at  variance  this  is  with  the  experience  of  the 
medical  world ! 

Cutting  out  hard  chancres  to  prevent  syphilis  is  not  a  scientific 
practice,  and  we  cordially  agree  in  this  opinion  of  the  author's.  He 
also  disapproves  of  treating  mouth  syphilis  with  mercury. 

Although  he  recommends  Cheyne's  soluble  bougies  in  the  treat- 
ment of  acute  gonorrhoea,  he  does  not  assert  with  the  originator  of 
the  antiseptic  bougie  treatment  that  cures  result  in  a  week's  time. 
We  would  like  to  say  more  regarding  the  merits  of  this  little  work, 
but  space  forbids.  It  certainly  gives  a  clearer,  broader,  and  more 
readable  account  of  venereal  diseases  than  can  be  found  in  any  book 
of  its  size. 


Surgical  Operations.  Part  II. :  Amputations,  Excision  of  Joints, 
Operations  on  Nerves.  By  Sir  William  MacCokmac.  London  : 
Smith,  Elder,  &  Co. :  1889. 

The  author  has  spared  no  trouble  in  making  the  steps  of  the 
various  operations  clear,  both  by  anatomical  drawings  and  diagrams, 
and  has  supplied  a  most  valuable  handbook  for  the  guidance  of 
students  and  operators.  As  an  example,  we  may  mention  that 
nine  illustrations  are  devoted  to  Syme's  amputation  at  the  ankle. 
The  directions  given  are  both  clear  and  reliable.  This  second  part 
is  more  than  three  times  the  size  of  the  first,  and  contains  a  vast 
amount  of  valuable  material. 


Board  School  Laryngitis.     By  Greville  Macdonald,  M.D. 
London  :  A.  P.  Watt :  1889. 

Dr  GtREVILLE  Macdonald  tells  us  that  for  some  time  past  he  has 
been  paying  attention  to  an  advanced  form  of  laryngeal  catarrh 
which,  to  his  mind,  possesses  certain  features  of  its  own,  and  occurs 
principally  among  the  female  teachers  in  elementary  schools.  He 
recognises  two  varieties,  the  varicose  and  the  hypertrophic.  He 
considers  that  they  are  due  to  the  same  cause,  unskilled  use  of  the 
voice,  and  that  to  excess. 

The  treatment  he  recommends  is  such  as  can  only  be  carried  out 
by  a  specialist,  but  Dr  Macdonald  fortunately  goes  further  than  mere 
treatment,  and  gives  some  excellent  rules  for  the  prevention  of  the 
mischief.  These  are  briefly  that  all  teachers  should  be  well  drilled 
in  the  production  of  the  speaking  as  well  as  the  singing  voice,  that 
classes  should  be  restricted  in  numbers  more  than  they  are  at 
present,  and  that  each  class  should  have  a  separate  room  suitable  in 
size  and  situation.     He  approves  of  the  suggestion  that  school 


1132  WHAT  MUST   I   DO   TO   GET   WELL?   ETC.  [jUNE 

boards  should  have  medical  officers  to  advise  them  upon  sanitation, 
overwork,  and  other  matters  of  educational  as  well  as  national 
importance. 


What  must  I  Do  to  get  Well  ?  and  Row  can  I  Keep  so  ?  By  One 
who  has  Done  it.  An  Exposition  of  the  Salisbury  Treatment. 
"Apicrrop  lixev  vSuyp.  London :  Sampson  Low,  Marston,  Searle, 
&  Rivington  (Limited)  :  1889. 

This  is  neither  a  political  squib  nor  a  teetotal  manifesto.  It  is 
a  very  innocent  and  evidently  quite  sincere  pufF  of  a  mode  of 
alimentation/  which  has  apparently  been  devised  by  a  Dr  Salisbury 
of  New  York.  It  is  written  by  a  woman  anxious  to  give  to  others 
the  help  she  herself  has  derived  from  this  treatment.  With  per- 
fectly pure  and  unselfish  motives,  it  bears  the  mark  of  sincerity  and 
of  a  childlike  confidence.  "  No  difficulties,  no  possibility  of  failure 
distresses  her."  "  I  declare  Dr  Salisbury's  system  to  be  a 
universal  remedy,  and  an  infallible  cure  in  whatever  stages  and 
under  whatever  conditions  remedy  and  cure  are  still  possible.  I 
go  further — 1  pronounce  Dr  Salisbury's  system,  thoroughly  and 
honestly  carried  out,  to  be  the  grand  preventive  of  disease  "  (pp. 
72,  73).  This  gifted  and  confident  lady  had  a  good  experience  of 
doctors,  having  had  thirty-eight  before  she  fell  in  with  the  thirty- 
ninth,  Dr  Salisbury ;  and  her  account  of  her  medical  experiences 
is  almost  as  unsatisfactory,  though  not  so  amusing,  as  Thomas 
Carlyle's.  The  universal  and  infallible  treatment  is  to  drink  at 
least  four  pints  daily  of  hot  water  at  certain  fixed  hours,  and  to  eat 
nothing  but  "minced  beef!!"  Truly  a  simple  dietary.  The 
directions  as  to  the  eating  and  drinking  are  most  precisely  given 
with  an  amusing  naivete,  and  the  happy,  healthy  cured  one  is  to 
look  forward  in  time  to  be  able  to  eat  two  pounds  of  minced  beef 
daily ;  no  vegetables,  pudding,  salad,  cakes,  etc.  The  dear  lady 
likes  good  things,  especially  cake,  so  she  has  always  to  eat  alone 
(p.  21).  What  a  charmingly  simple  thing  life  would  be.  Nothing 
to  provide  but  hot  water  in  kettles  and  two  pounds  of  minced  beef 
(prepared  by  a  special  American  griller,  price  2s.  6d.)  (p.  18).  Each 
guest  is  to  eat  alone ;  so  to  give  a  party  one  would  need  to  prepare 
numerous  little  hutches,  each  with  a  guest  and  a  locked  door  and  a 
kettle.  Five  minutes  would  do  to  consume  the  minced  beef,  and 
then  what  a  nice  evening  of  social  delight  after  such  a  meal.  Dif- 
ficulties rise  to  the  mind  of  the  too  imaginative  reader.  The  minced 
beef  is  to  be  made  of  the  best  bits  only  (see  p.  16).  Who  is  to  eat 
what  remains?  Gardens  will  be  unnecessary  ;  shepherds  and 
sheep  farms  at  a  discount.  Wool  will  go  out  of  fashion,  and  we 
must  clothe  ourselves  in  the  hides  of  the  bullocks,  to  feeding  of 
which  all  possible  ground  is  to  be  devoted.  No  more  arable  land 
will  be  needed.     The  question  of  food  supply  must  be  altered. 

Seriously,  it  is  a  most  absurd  little  work  j  any  attempts  at  physi- 


1889.]  WHAT   MUST  I   DO   TO   GET  WELL?   ETC.  1133 

ology  and  pathology  which  it  contains  are  not  up  to  the  standard  ot 
a  board  school;  and  the  quotations  from  Dr  Salisbury,  if  accurate, 
show  that  his  pathology  is  also  very  different  from  that  of  the  rest 
of  the  profession. 

To  those  of  us  who  remember  our  great  prophet  of  hot  water 
there  is  an  amusing  contrast,  when  we  recall  his  horror  at  beef. 
With  him  chickens  and  rabbits  would  be  the  only  survivors  of 
animals  for  the  food  of  man. 


MEETINGS  OF  SOCIETIES. 


MEDICO-CHIRURGICAL    SOCIETY    OF    EDINBURGH. 

SESSION  LXVIII. — MEETING  VI. 

Wednesday^  20th  February  1889. — Dr  Smith,  President,  in  the  Chair. 

(Continued  from  page  1056.) 

Dr  Peddie  said, — I  am  glad  that  our  Council  has  brought  up  this 
subject  for  discussion,  seeing  that  Mr  Morton's  draft  Restorative 
Home  Bill  is  at  present  in  the  hands  of  the  Secretary  for  Scotland ; 
and  it  is  very  satisfactory  that  Dr  Stewart  has  at  their  request 
undertaken  to  explain  the  scope  of  that  Bill,  and  those  delicate  and 
important  points  which  are  concerned  in  the  question.  I  hope 
that  this  meeting  of  the  Society  may  be  as  unanimous  in  opinion 
on  the  question  as  was  the  case  thirty-one  years  ago,  when  I 
brought  the  matter  before  it,  and  read  a  paper  on  the  subject 
That  paper  when  published  was  circulated  extensively;  and  the 
suggestions  then  made,  following  as  they  did  the  recommendation 
three  years  previously  by  the  Scottish  Lunacy  Commission  of  1855 
in  their  Report  of  1857,  for  "  prolonged  detention  in  asylums  of 
cases  of  insanity  arising  from  the  habit  of  intemperance,"  created 
a  widespread  interest,  and  was  most  favourably  commented  on  at 
the  time  in  almost  every  newspaper  and  journal  in  the  country. 

Between  that  time  and  the  passing  of  the  Habitual  Drunkards 
Act  twenty-one  years  elapsed.  Dr  Stewart  has  given  something 
of  a  sketch  of  the  fits  and  starts  of  the  agitation  on  the  question 
during  that  period  of  time ;  and  the  outcome  of  all  the  agitation 
was  the  present  Act.  The  Bill  then  brought  in — it  was  not  the 
first  Bill — by  Dr  Cameron,  was  a  strong  measure  on  the  subject, 
but  it  came  out  of  Parliament  an  emasculated  one,  a  very  feeble 
Act,  which  has  done  very  little,  but  certainly  some  good, 
as  it  has  advanced  the  question  somewhat;  but  now  we  have 
before  us  a  draft  Bill  which,  if  carried,  will,  I  believe,  accomplish 
a  great  deal  more,  although  it  certainly  cannot  altogether  meet  the 
grievous  evil  which  exists  in  our  midst.  There  is  no  wonder  that 
the  Act  of  1879  is  disappointing,  because  it  dropped  the  essential 


1134  MEETINGS   OF  SOCIETIES.  [jUNE 

clause  for  good,  namely,  the  compulsory  clause.  The  voluntary 
clause  was  likewise  almost  valueless  by  being  hedged  with 
obnoxious  and  debarring  requirements.  There  was  also  dropped 
from  the  proposed  measure  another  provision,  viz.,  that  clause  for 
extending  the  Act  beyond  the  upper  and  middle  classes.  Any 
provisions  made  should  be  available  for  those  of  the  labouring, 
pauper,  and  criminal  drunkards  as  well.  The  preamble  of  the 
Bill  now  before  us  has  been  read ;  and  so  far  as  I  am  able  to  give 
an  opinion,  having  given  a  good  deal  of  attention  to  the  matter 
during  past  years,  it  is,  I  believe,  judiciously  constructed,  and  I 
do  not  know  that  we  could  get  a  better  Act  than  what  may 
be  founded  upon  it.  It  has  been  drawn  upon  the  lines  of  the 
Eeport  of  the  Select  Committee  of  the  House  of  Commons  in 
1872,  and  signifies  what  seems  most  desirable  in  the  case.  In 
complying,  therefore,  Mr  President,  with  the  request  of  your 
Council  to  follow  the  lead  of  Dr  Grainger  Stewart  in  intro- 
ducing the  subject  for  this  evening's  discussion,  I  hope  I  may 
not  tread  too  much  on  the  ground  gone  over  by  him  while 
emphasizing  in  some  measure  what  has  been  said  on  some  of 
the  most  important  features  of  the  draft  Bill.  This  I  have 
attempted  to  note  under  three  heads,  but  will  add  as  a  fourth 
what  I  consider  to  be  a  defect  in  the  proposed  Act. 

1.  The  assertion  in  the  Bill  that  it  has  to  deal  with  a  special 
form  of  mental  disorder ;  and  that  its  provisions  proceed  on  the 
supposition  of  the  probability  that  cure  or  alleviation  may  fre- 
quently be  effected. 

2.  That  any  arrangements  for  the  establishment  of  "  restorative 
homes,"  unless  providing  for  easy  voluntary  admission  to  such, 
and,  if  need  be,  for  compulsory  enforcement  and  power  to  detain, 
must  cripple  and  seriously  nullify  legislation  designed  for  personal 
and  relative  benefit. 

3.  That  the  safeguards  afforded  by  this  Bill  are  amply  sufficient 
for  the  protection  of  the  liberty  of  the  subject,  and  all  interests 
connected  with  individuals,  families,  and  the  public. 

4.  That  the  defect  of  the  proposed  Act  is  in  its  limited  applica- 
tion to  the  well-to-do  classes,  and  in  not  extending  its  provisions 
to  the  labouring,  the  pauper,  and  the  criminal  classes. 

1.  The  assertion  in  the  Bill  that  it  has  to  deal  with  a  special 
form  of  mental  disorder ;  and  that  its  provisions  proceed  on 
the  supposition  of  the  probability  that  cure  or  alleviation 
may  frequently  be  effected. 

The  right  understanding  that  a  morbid  mental  condition  exists  in 
those  individuals  for  whom  legislation  is  sought,  lies  at  the  bottom 
of  the  whole  question,  a  condition  which  requires  mixed  physical, 
mental,  moral,  and  religious  treatment  in  a  home  or  a  retreat,  as 
if  they  were  patients  in  an  hospital,  but  not  in  an  asylum,  if  that 
can  be  avoided. 


1889.]  MEDICO-CHIRUEGICAL  SOCIETY  OF  EDINBURGH.  1135 

It  is  again  and  again  asked  by  those  who  are  opposed  to  legis- 
lation in  the  case  of  habitual  drunkards,  How  are  you  to  draw  the 
line  between  drinking  the  vice  and  drinking  the  disease,  and  con- 
sequently carry  out  a  just  administration  of  law  as  regards  con- 
trol? But  the  diagnosis  in  individual  cases  must  be  perfectly 
easy  to  common-sense  observers ;  indeed,  it  should  be  more  easy 
than  in  the  general  run  of  insane  cases,  or  sometimes  of  medical 
disease ;  for  not  only  will  an  opinion  be  formed  from  physical 
manifestations  which  are  sufficiently  marked,  but  substantiated 
and  confirmed  as  they  must  always  be  by  what  is  seen  in  the  con- 
duct of  each  person,  and  from  the  testimony  of  reliable  witnesses 
as  to  existing  circumstances  and  statements  of  historical  fact. 
The  preamble  of  the  proposed  Bill  read  by  Dr  Stewart  is  most 
admirable  as  to  the  points  and  limitations  for  which  an  Act  is 
designed,  both  in  the  way  of  definition  and  description,  and  could 
scarcely,  I  think,  be  improved. 

The  habitual  drunkard  is  not  the  ordinary  social  drinker — one 
who  imbibes  freely  even  to  intoxication  at  public  feasts  or  at 
markets,  or  with  boon  companions,  or  who  soaks  a  great  deal  daily, 
or  resorts  to  frequent  "  nips  "  for  the  love  of  the  drink,  while  yet 
tolerably  fit  to  discharge  the  ordinary  duties  of  life.  But  he  is 
one  whose  desire  has  originated  as  a  disease,  or  has  passed  from 
intemperance  into  a  condition  in  which  there  is  an  irresistible, 
ungovernable,  uncontrollable  craving  for  intoxicants  which  he 
gives  way  to  solitarily,  stealthily,  and  deceitfully;  and  who  is 
notoriously  untruthful  as  to  the  desire  and  its  indulgence,  and 
utterly  regardless  of  consequences  to  himself  or  others,  even  in 
spite  of  the  most  sacred  social  and  moral  obligations. 

Examples  of  all  these  characteristics  I  could  easily  supply  from 
personal  experience  did  your  time  permit ;  but  I  am  sure  that  all 
present  of  much  experience  in  practice  must  be  able  to  recall 
instances  in  corroboration  of  what  I  have  stated.  I  shall  only 
quote  one  short  passage  from  the  evidence  I  gave  before  the 
Select  Committee  of  the  House  of  Commons  in  1872  as  a  sample 
of  what  I  have  often  met  with  {Report,  p.  49,  answer  to  question 
939,  twelfth  line  from  top) — "  I  never  yet  saw  truth  in  relation  to 
drink  got  out  of  one  who  was  a  dipsomaniac ;  he  has  sufi&cient 
reason  left  to  tell  these  untruths  and  to  understand  his  position, 
because  people  in  that  condition  are  seldom  dead  drunk :  they  are 
seldom  in  the  condition  of  total  stupidity ;  they  have  generally  an 
eye  to  their  own  affairs,  and  that  is  the  main  business  of  their 
existence,  namely,  how  to  obtain  drink.  Then  they  will  resort  to 
the  most  ingenious,  mean,  and  degrading  contrivances  and  prac- 
tices to  procure  and  conceal  liquor,  and  all  this,  too,  while  closely 
watched,  and  succeed  in  deception,  although  almost  fabulous 
quantities  are  daily  swallowed.  In  many  of  those  cases  with 
which  I  have  had  to  do,  ladies  as  well  as  gentlemen — and  the 
former  are   generally   the   worst   so   far   as  untruthfulness  and 


1136  MEETINGS   OF   SOCIETIES.  [jUNE 

ingenuity  are  concerned — I  have  had  the  most  solemn  assevera- 
tions that  not  a  drop  of  liquor  had  crossed  their  lips  for  many 
hours,  when  they  could  not  have  walked  across  the  floor ;  that 
not  a  drop  of  liquor  was  within  their  power,  when  I  would  find 
bottles  of  liquor  wrapped  up  in  stockings  and  other  articles  of 
clothing,  concealed  in  trunks  and  wardrobes,  put  up  the  chimneys 
and  under  beds  or  between  mattresses ;  and  on  a  late  occasion,  in 
the  case  of  a  lady,  after  all  means  had  failed  in  discovering  where 
the  drink  came  from,  on  making  a  strict  personal  examination 
found  a  bottle  of  brandy  concealed  in  the  armpit,  hung  round  the 
neck  with  an  elastic  cord,  so  that  she  might  help  herself  as  she 
pleased.  The  next  morning,  on  seeing  that  the  drunkenness  still 
continued  and  that  something  more  was  to  be  got  at,  there  was 
actually  found  a  bottle  of  brandy  tied  in  the  same  way  round  the 
loins  and  placed  between  her  thighs.  Such  is  but  an  instance  of 
the  determination  to  obtain  the  wished-for  supplies." 

This,  therefore,  must  be  considered  a  diseased  condition  closely 
allied  to,  if  not  an  actual  form  of  insanity.  Again  and  again 
memorials  have  been  sent  to  Government,  signed  by  the  most 
eminent  men  in  our  profession  here  and  elsewhere,  expressing  their 
opinion  in  these  terms,  "that  habitual  drunkenness  is  a  disease 
closely  approximated  in  a  great  number  of  cases  to  insanity,  and 
susceptible  of  successful  treatment."  Whether  arising  from  pro- 
tracted vicious  habit,  or  from  constitutional  organization,  or  some 
disease  or  injury,  the  craving  for  drink  is  an  impulse  as  strong  as 
that  in  the  kleptomaniac,  or  suicidal  or  homicidal  monomaniac ;  and 
while  it  differs  from  all  other  kinds  of  drinking,  it  is  characteristic 
of  a  considerable  portion  of  the  ordinary  insane,  because,  when 
under  the  fit,  as  there  is  a  total  annihilation  of  self  control,  the 
individual  must  surely  be  said  to  have  lost  the  most  distinguish- 
ing attribute  of  sanity. 

Besides,  in  such  cases  there  is  evident  proof  that  the  morbid 
proclivity  has  an  intimate  connexion  with  brain  structure  and 
function,  since  it  is  found  so  often  the  outcome  of  Heeedity.  I 
have  seen  many,  and  I  know  of  many  more  remarkable  examples 
of  this  which  I  could  quote  if  time  permitted ;  and  in  life  assur- 
ance investigations  into  family  history  I  have  found  many  instances 
of  fathers,  mothers,  brothers,  and  sisters,  grandparents,  uncles, 
aunts,  and  cousins,  having  been  intemperate  in  various  forms 
and  degrees.  Also,  it  is  well  known,  and  I  have  seen  many 
instances  in  the  course  of  practice  and  in  assurance  examinations, 
of  families  thus  alcoholically-toxically  tainted  having  among  their 
members  those  who  were  actually  insane,  or  epileptic,  or  hydro- 
cephalic, or  affected  with  other  forms  of  nervous  disease, — inebriety 
thus  producing  in  offspring  its  impress  on  the  brain,  which  crops 
up  in  some  form  or  degree,  if  not  in  the  early  stage  of  life,  at 
least  at  some  more  advanced  period.  Nay,  I  have  known  mere 
children  and  those  in  early  youth  exhibiting  the  alcoholic  pro- 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH,  1137 

pensity ;  and  I  have  no  doubt  our  psychologist  Fellows  now 
present  must  have  seen  frequent  instances  of  this  fact.  I  am  sure 
also  that  they  must  have  frequently  seen  the  alcoholic  propensity 
manifested  in  those  actually  insane,  and  could  also  give  us  some 
information  regarding  the  worst  types  of  dipsomania,  who  are  the 
most  troublesome  inmates  of  any  asylum. 

As  additional  crucial  proofs  of  the  connexion  of  a  drink-craving 
propensity  with  brain  disorder,  I  would  simply  notice  the  fact  of 
the  former,  sometimes  occurring,  in  the  worst  degrees,  from  blows 
on  the  head,  sunstroke,  nervous  shock  from  any  cause,  haemorrhage, 
and  some  fevers.  And,  finally,  on  this  branch  of  the  argument  I 
would  notice  the  singular  mental  associations  of  habitual  drunken- 
ness with  crime.  These  individuals,  in  police  court  language  called 
"habituals,"  have  generally  a  low  mental  development  or  twist. 
They  vibrate  between  our  police  court  and  the  Calton  gaol,  seldom 
out  of  the  latter  many  days  or  weeks,  and  that  from  year  to  year, 
to  the  great  cost  of  the  country.  Eegarding  these  psychological 
puzzles  our  excellent  sanitary  officer  may,  perhaps,  give  us  inter- 
esting information,  and  also  tell  us  if  he  has  observed  any  curious 
uniformity  in  crimes  committed  under  the  influence  of  more  or  less 
drink.  On  this  point,  perhaps,  I  may  be  again  permitted  to  quote 
from  my  evidence  before  the  Select  Committee  of  the  House  of 
Commons  the  following  facts  furnished  to  me  by  the  late  Sheriff 
Barclay  of  Perth.^  He  said:  "Between  the  years  1844  and  1865 
one  woman  was  committed  to  prison  137  times  for  being  drunk, 
and  when  drunk  her  invariable  practice  was  to  smash  windows. 
Then  there  was  a  man  who,  when  drunk,  stole  nothing  but  Bibles; 
he  was  an  old  soldier  wounded  in  the  head ;  when  drunk,  the 
objects  of  theft  were  always  Bibles ;  and  he  was  transported  for 
the  seventh  act  of  Bible  stealing.  Then  another  man  stole  nothing 
but  spades ;  a  woman  stole  nothing  but  shoes ;  another,  nothing 
but  shawls ;  and  there  was  a  curious  case  (the  indictment  against 
whom  I  have)  of  a  man,  named  Grubb,  who  was  transported 
for  the  seventh  act  of  stealing  a  tub;  there  was  nothing  in  his 
line  of  life,  and  nothing  in  his  prospects,  no  motive  to  make 
him  specially  desire  tubs ;  but  so  it  was,  that  when  he  stole,  it 
was  always,  excepting  on  one  occasion,  a  tub." 

Now,  an  important  question  for  consideration,  after  what  has 
been  said  of  the  habitual  drunkard's  condition,  is.  Can  it  be  cured  ? 
I  unhesitatingly  say  that  in  a  considerable  number  of  cases  it  is 
curable ;  and  that  in  a  larger  proportion,  with  suitable  legislative 
arrangements,  it  might  be.  As  in  insanity,  it  is  curable  in  the 
same  sense  that  other  diseases  are.  The  more  recent  and  acute  the 
case  is  when  taken  under  care  and  treatment,  the  sooner  it  is  likely 
to  be  cured ;  while  the  more  chronic  and  confirmed  it  has  become, 
the  more  difficult  will  it  be  to  accomplish  that.     So  in  habitual 

1  Evidence  before  the  Select  Committee  of  the  House  of  Commons,  1872,  page  50, 
answer  949. 

EDINBURGH   MED.   JOURN.,   VOL.    XXXIV. — NO.    XII,  7  E 


1138  MEETINGS   OF    SOCIETIES.  [JUNE 

drunkards,  from  the  imperiousness  of  the  desire  and  habit,  and 
the  unwillingness  to  be  under  restraint,  they  are  seldom  brought 
early  enough,  if  ever,  under  the  necessary  mixed  medical,  mental, 
and  moral  reformatory  treatment;  and  as  there  is  gener- 
ally the  greatest  difficulty  in  getting  them  to  submit  to  suffi- 
ciently prolonged  control,  and  no  power  to  enforce  such,  it  is 
not  fair  to  push  aside  as  visionary  the  reasonable  expectation 
which  even  the  present  results,  under  great  disadvantages,  fully 
justify.  The  experience  of  our  private  licensed  homes  or  retreats 
in  Scotland  and  England  cannot  be  satisfactorily  ascertained  from 
the  above  causes,  and  the  absence  of  Grovernment  or  other  inspec- 
tion, and  of  statistics ;  but  I  know  of  several  males  and  females 
treated  in  different  establishments  for  considerable  periods  of  time, 
who  have  done  well  afterwards.  Even  the  lady  whose  case  I  read 
to  you,  and  seemingly  so  unpromising,  was  ultimately  cured.  A 
few  days  since  I  had  a  note  from  Dr  Norman  Kerr  of  London,  the 
President  of  "  The  Society  for  the  Study  and  Cure  of  Inebriety," 
regarding  "  The  Dalrymple  Home  for  Male  Inebriates,  Ricksman- 
worth,  Herts,"  which  home,  he  said,  might  be  safely  referred  to 
from  its  being  the  only  disinterested  home  under  the  Act  (that  is, 
not  a  private  adventure),  and  which  issues  statistics  annually,  so 
as  to  be  of  permanent  value.  Dr  Kerr  says  that  "  of  the  115  cases 
discharged  from  the  home  up  till  31st  January  1888,  52  were  then 
doing  well.  Of  course  the  time  is  too  short  to  justify  the  claim  of  all 
these  as  cures  ;  but,"  Dr  Kerr  av6rs,  that  "from  my  experience,  one- 
third  is  as  large  a  proportion  as  can  reasonably  be  hoped  for  in  the 
case  of  males."  As  yet  in  England  there  is  no  licensed  home  under 
the  Act  for  females,  but  there  are  seven  for  males.  However,  it  is 
the  general  belief  that  with  an  improved  law  and  suitable  arrange- 
ments, the  percentage  of  cure  may  be  very  considerable.  I  could 
quote  in  support  of  this  opinion  from  a  number  of  eminent  and 
respected  medical  men  in  this  country  and  in  America,  whose 
opinions  are  worth  having;  but  I  shall  only  now  notice  the 
opinions  of  two,  who  are  well  known  to  all  of  us.  The  one  is  that 
of  Sir  Arthur  Mitchell,  who  said  in  his  evidence  before  the  Select 
Committee  of  1872, — ''We  should  hope  to  obtain  a  cure  by  pro- 
longed compulsory  abstinence  under  conditions  favourable  to 
health.  Whether  this  hope  would  or  would  not  be  realized  I 
cannot  tell ;  our  experience  in  the  matter  in  Scotland  is  far  from 
encouraging ;  permanent  and  satisfactory  cures  are  certainly  very 
rare ;  hut  the  exjMriment  has  never  yet  been  quite  fairly  made,  and 
it  cannot  be  so  made  without  special  legislation.  If  it  were  fully 
and  fairly  made,  the  expectation  of  good  results,  I  think,  is  a 
reasonable  one."  ^  Then  Sir  Arthur  goes  on  in  the  same  answer  to 
his  questioner  to  say,  that  as  to  the  comfort  of  such  legislation  to 
families,  friends,  and  society,  "  there  are  no  uncertainties."     The 

1  Evidence  before  the   Select  Committee   on   Habitual  Dninkarcls,   1872, 
p.  65.     Ans.  to  query  1196. 


1889.]  MEDICO-CHI RURGICAL   SOCIETY   OF   EDIXBURGH.  1139 

other  opinion  is  that  of  our  friend  Dr  Batty  Take,  which  I  see  in 
a  Eeport  of  the  Saughton  Hall  establishment  for  1887,  dated  1888, 
in  which  he  states  there  were  two  dipsomaniacs  treated  under  the 
voluntary  permission  law ;  and  going  on  to  speak  generally  of 
dipsomania,  he  says, — "Even  amongst  their  number  many  have 
submitted  to  treatment  for  lengthened  periods,  and  their  subsequent 
history  has  shown  that  this  intractable  form  of  insanity  can  be 
permanently  overcome.  The  records  of  this  asylum  show  that 
many  bad  cases  of  dipsomania  have  been  either  cured  or  very 
materially  relieved."  This  I  consider  as  very  valuable  testimony, 
and  I  feel  assured  that  Dr  Clouston  could  corroborate  the  same. 
In  regard  to  the  American  experience,  about  which  much  has 
been  said  in  some  quarters,  I  think  we  ought  to  deal  with  it 
generously,  and  without  prejudice ;  for  while  there  may  have  been 
some  exaggeration  regarding  the  percentage  of  cures,  and  confusion 
regarding  the  nature  of  the  cases  under  treatment,  as  in  our 
own  country,  where  the  homes  are  not  licensed  or  inspected,  the 
modes  of  treatment  and  the  reports  of  success  cannot  be  trusted ; 
yet,  on  the  other  hand,  I  think  there  has  been,  as  regards 
American  institutions  for  inebriates,  a  very  great  amount  of  mis- 
representation, for  I  know  there  are  a  number  of  excellent  homes 
in  the  States  and  in  Canada,  conducted  in  the  same  excellent  way 
as  in  our  Dalrymple  Home,  under  the  superintendence  of  scientific, 
benevolent,  and  honest  men,  doing  most  excellent  work.  The 
American  physicians  have  shown  much  more  earnestness  and  more 
of  a  scientific  spirit  in  the  study  and  treatment  of  inebriety  during 
the  last  twenty  years  than  we  have  done,  as  the  reports  of  their 
"Association  for  the  Study  and  Cure  of  Inebriety"  and  their 
Quarterly  Journal  of  Inebriety  show  ample  proof.  And  from  what 
I  have  been  able  to  make  out  from  these,  they  seem  to  have  a  fair 
claim  to  33  per  cent,  of  cures — cures  as  permanent  as  can  be  said 
of  cures  of  any  disease.     But  I  hasten  on  to  say — 

2.  That  any  arrangements  for  the  establishment  of  homes,  unless 
providing  easy  vohmtary  admission,  and,  if  need  be,  co7iipul- 
sory  enforcement  and  powers  for  detention,  must  cripple  and 
almost  nullify  legislation  for  individual  or  relative  benefit. 

An  important  feature  in  the  proposed  Act,  different  from  the 
present  amended  Act  is,  that  voluntary  admission  is  not  to  be 
public  and  deterrent,  but  private,  simple,  and  easy.  Instead  of 
an  appearance  before  a  justice  of  the  peace,  magistrate,  or  sheriff, 
as  at  present,  with  two  witnesses,  and  making  then  and  there  a 
declaration  that  he,  the  person,  desires  to  be  admitted  to  a  home,  as  he 
has  been  and  is  a  habitual  drunkard,  the  transaction  is  proposed  to 
be  merely  with  the  superintendent  of  a  home  (licensed,  of  course), 
which  application,  according  to  the  schedule  of  the  Act,  is  signed 
by  the  person,  and  attested  by  two  respectable  witnesses,  engaging 
that  he  shall  remain  in  the  home,  subject  to  the  provisions,  rules, 


1140  MEETINGS   OF   SOCIETIES.  [JUNE 

and  regulations  of  the  Act,  until  discharged  in  accordance  with 
the  same.  One  of  these  provisions  is  that  the  person  or  "patient," 
according  to  the  Act,  shall  remain  at  least  twelve  months  under 
treatment,  unless  circumstances  render  it  expedient  that  he  should 
be  discharged  earlier. 

We  all  know  the  difficulty  of  prevailing  on  a  habitual  drunkard 
to  place  himself  under  restraint.  A  propensity  so  deeply  rooted 
in  the  constitution,  so  enslaving  and  irresistible,  blunts  the  better 
feelings  of  human  nature  and  reasoning  powers  as  regards  promised 
benefit,  and  incapacitates  him  from  appreciating  the  advice,  or  to 
be  moved  by  the  entreaties,  tears,  or  threats  of  friends.  Thus  in 
my  own  experience,  after  much  interviewing  and  correspondence, 
even  at  the  eleventh  hour,  when  consent  had  been  obtained  and  a 
home  chosen,  perhaps  in  only  one  out  of  a  dozen  of  instances  could 
submission  be  obtained.  Therefore  if  persuasion  proved  ineffectual 
in  producing  consent  to  enter  a  home,  the  compulsory  enforcement 
clause  which  stands  in  the  proposed  Bill  will  settle  the  matter. 
This  alternative  hanging  over  the  head  of  the  person  is  therefore 
likely  to  make  him  prefer  a  voluntary  surrender,  which  can  so 
easil}'"  be  made,  to  the  ordeal  of  magisterial  committal.  The 
experience  of  such  powers  in  Canada  and  in  most  of  the  American 
States  to  draft  persons  into  homes,  amply  proves  that  while 
voluntary  surrenders  are  very  numerous,  instances  of  enforced 
treatment  are  very  few. 

3.  That  the  safeguards  afforded  by  this  Bill  are  amply  sufficient 
for  the  protection  of  the  liberty  of  the  subject,  and  all  the  in- 
terests connected  with  individuals,  families,  and  the  public. 

First  of  all,  it  is  no  small  or  unimportant  feature  in  the  proposed 
Bill  that  the  Board  of  Commissioners  in  Lunacy  is  to  be  the  central 
authority  under  the  Act.  The  well-known  constitution  and 
character  of  that  Board  surely  gives  the  very  best  guarantee  for  just 
administration.  They  are  to  have  the  licensing  of  all  the  homes ; 
the  sanctioning  all  the  internal  arrangements,  rules,  and  regula- 
tions, not  only  for  district  homes  established  by  public  grants,  but 
for  all  private  homes,  as  they  must  all  equally  come  under  the 
Act.  Then  as  to  the  safeguards  connected  with  admission  to  any 
of  the  homes,  district  or  private,  the  superintendent  of  the  home 
to  which  the  patient  has  gone  must  notify  to  the  Board  of  Lunacy 
that  fact  within  two  days  of  entrance,  accompanied  with  a  full 
statement  of  the  case ;  and  should  the  Board  not  be  satisfied  with 
this  admission,  an  immediate  discharge  will  be  ordered.  Then  in 
regard  to  a  compulsory  committal,  the  safeguards  are,  that  before 
the  sheriff  will  grant  a  warrant  in  any  case,  the  applicant 
for  that  warrant  must  be  a  member  of  the  family  or  a  near 
relative  of  the  person,  or  a  friend  taking  an  interest  in  him, 
or  a  magistrate  in  the  interest  of  the  public,  setting  forth  in 
a  solemn   declaration  the   facts  and  circumstances  of  the   case. 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  1141 

accompanied  with  a  certificate  from  a  medical  man,  on  soul  and 
conscience,  that  he  has  seen  the  person  within  seven  days ;  and  if 
there  are  no  private  friends,  then  the  certificates  of  two  medical 
men.  Then,  of  course,  a  patient,  whether  under  voluntary  or 
compulsory  control  in  a  home,  has  the  right  of  appeal  at  any 
time  to  the  Lunacy  Board  or  the  Secretary  for  Scotland  for  a 
discharge,  if  he  considers  that  there  has  been  undue  or  im- 
proper interference  with  personal  liberty;  or  if  he  thinks  he 
has  good  cause  for  complaint  as  to  treatment  received  in  the 
home ;  or  some  cause  which  makes  it  specially  desirable  that  he 
should  be  discliarged ;  or  which  discharge  is  urgently  requested 
by  his  relatives  or  friends.  Thus  it  will  be  seen  that  with  all  these 
precautions,  and  with  regular  inspection  of  all  the  homes,  as  in  the 
case  of  carrying  out  the  lunacy  laws  in  regard  to  asylums,  the  best 
interests  of  individuals,  of  families,  and  friends  are  sufficiently 
safeguarded. 

Of  course,  say  what  one  may,  there  will  be  a  hue-and-cry  raised 
by  certain  people  regarding  an  Act  of  this  kind  jeopardizing  the 
liberty  of  the  subject.  However,  as  I  have  said  elsewhere  that  it 
is  certainly  an  overstrained  delicacy  in  legislation  which  checks 
interference  with  a  class  of  cases  necessarily  occasioning  much 
private  misery  and  public  expenditure,  as  the  records  of  the  courts 
of  law,  the  church,  of  our  prisons,  poorhouses,  and  lunatic 
asylums  amply  prove.  Justice,  humanity,  political  economy,  and 
expediency  all  round,  therefore,  call  for  legal  interposition  and  for 
facility  to  control  and,  if  possible,  to  cure  the  habitual  drunkard, 
since  medical  and  other  advice  or  moral  suasion  are  of  no  avail  in 
influencing  his  actions ;  and  surely,  when  such  is  the  case,  it  is  the 
manifest  duty  of  a  wise  government  to  exercise  over  all  its  sub- 
jects a  paternal  relationship.  In  a  great  many  ways  the  liberty  of 
the  subject  is  most  properly  interfered  with  for  personal  benefit, 
for  the  protection  or  good  of  others,  for  the  amenity  of  a  neigh- 
bourhood, or  the  general  welfare  of  the  public ;  and  why  not  in 
cases  and  circumstances  so  clamant  as  those  pointed  out  ? 

4.  Lastly,  the  defect  that  I  see  in  this  proposed  Act  is  the 
absence  of  provisions  reaching  down  to  the  labouring,  the 
pauper,  and  the  criminal  classes. 

It  was  thought,  however,  better  in  the  first  instance  to  seek 
legislation  only  for  such  as  were  able  to  pay  board  for  treatment 
in  the  restorative  homes,  which  would  thus  to  a  considerable 
extent  prove  self-supporting,  otherwise  the  cry  against  increased 
taxation  might  shipwreck  the  proposed  Act,  I  hope,  however, 
that  ere  long  the  Act  may  be  extended  to  such  classes,  for  whilst 
the  vice  of  drunkenness  in  all  its  most  degrading  and  disgusting 
forms  is  more  prevalent  in  the  lower  strata  of  our  population,  dis- 
turbing peace  and  prosperity  in  private  life,  and  endangering  the 
safety  of  the  public,  there  are  in  it  also  a  greater  number  of  the 


1142  MEETINGS   OF   SOCIETIES.  [jUNE 

worst  type  of  inebriates,  namely,  genuine  dipsomaniacs,  dragging 
down  to  beggary  and  wretchedness  numbers  of  those  who  are  well- 
to-do,  and  thus  largely  increasing  disease,  destitution,  and  crime, 
and  consequently  continuous  gravitation  to  our  hospitals,  poor- 
houses,  asylums,  and  prisons,  imposing  a  correspondingly  heavy 
burden  on  local  taxation  and  the  funds  of  the  nation. 

Of  course  private  enterprise  or  philanthropic  associations  cannot 
be  expected  to  establish  inebriate  homes  or  sanatoria  so  as  to  meet 
altogether  the  exigencies  of  this  great  social  evil ;  but  municipal 
and  parochial  authorities,  perhaps  supplemented  to  some  extent  by 
Government,  could  accomplish  most  excellent  results.  From  work 
done  and  wages  earned  by  the  inmates  of  such  institutions,  the 
expense  of  maintenance  might  to  a  large  extent  be  met  and  some- 
thing over  and  above  gained  for  the  benefit  of  their  families,  or,  in 
the  absence  of  such,  for  his  or  her  own  use  when  the  period  of  control 
terminates  ;  thus  also  habits  of  industry  and  providence  cultivated, 
would  prove  excellent  counteractives  against  a  return  to  drinking 
habits ;  and  other  agencies — physical,  mental,  moral,  and  especially 
religious — would  be  the  surest  means  of  generating  self-esteem,  and 
strengtliening  the  power  of  self-control. 

Then  as  to  the  large,  troublesome,  dangerous,  and  expensive  class 
of  inebriates,  so  well  known  to  our  magistrates,  police,  and  prison 
officials,  as  criminal  drunkards,  Government  ought  unquestionably 
to  make  some  provision  in  a  Habitual  Drunkards  Act,  by  which 
suitable  treatment  could  be  carried  out  in  reformatories  either  in 
connexion  with  or  altogether  distinct  from  prisons.  Inebriates  of 
this  class  are  at  present  almost  irretrievably  sunk  in  the  lowest 
depths  of  the  social  scale.  They  are  almost  constantly  resident  in 
police  cells  or  prisons  from  oft  repeated  sentences  on  account  of 
assaults,  or  crimes,  committed  to  obtain  drink  or  under  the  influ- 
ence of  it ;  many  of  them  are  most  dangerous,  and  all  are  pests  in 
society,  and,  as  must  be  admitted,  most  costly  to  the  country, 
while  it  is  notorious  that  not  the  smallest  benefit  is  produced  by 
imprisonment. 

Of  course  in  sucli  establishments  the  punitive  element  could  not 
altogether  be  separated  from  the  reformatory ;  and  the  expense  of 
upholding  them  would  to  a  considerable  extent  fall  on  prison 
boards ;  but  I  firmly  believe  that  the  good  accomplished  in  them  by 
strict,  yet  kindly  and  judicious  management,  there  would  in  time 
be  ample  compensation  to  the  State,  and  probably  a  large  saving 
of  the  at  present  utterly  useless  expenditure.  Here  inmates 
would  be  obliged  to  work,  in  the  first  instance,  for  their  own  main- 
tenance, and  possibly  by  good  conduct  win  something  over  to  help 
themselves  when  the  term  of  restraint  expired.  Direct  commit- 
ment by  the  magistrates  to  such  reformatories  might  in  many  in- 
stances be  judiciously  made  after  three  or  four  convictions  without 
passing  the  criminal  through  a  prison,  which  all  experience  has 
shown  to  be  utterly  useless  as  a  preventive  of  future  offences,  and 


1889.]  MEDICO-CHIRURGICAL   SOCIETY   OF   EDINBURGH.  1143 

a  monstrous  waste  of  money  as  regards  this  class  of  offenders. 
But  if  it  must  be  continued  so  to  some  extent  as  a  mark  of  justice 
on  account  of  crime  committed,  the  prisoner  might  be  transferred  to 
the  reformatory  in  some  cases  before  the  period  of  sentence  expires, 
or  at  any  rate  then,  by  a  warrant  from  a  magistrate  or  sheriff  for 
such  prolonged  detention  in  it  as  circumstances  justify,  when  he 
would  be  subjected  to  those  various  influences  already  spoken  of. 
By  such  means  I  firmly  believe  a  considerable  percentage  might 
be  saved  from  an  otherwise  almost  certain  lapse  into  the  old  evil 
ways,  and  a  speedy  return  to  prison  life,  or  a  curse  on  society. 
Without  pursuing  further  this  important  branch  of  my  subject,  I 
would  refer  to  the  evidence  I  gave  before  the  Select  Committee 
of  the  House  of  Commons  in  1872,^  and  especially  to  the  sugges- 
tions for  legislation,  which  that  Committee  did  me  the  honour  to 
accept,  and  insert  in  full  in  the  Appendix  to  their  Keport  (No.  3, 
pp.  186-190). 

{To  be  continued.) 


OBSTETRICAL  SOCIETY  OF  EDINBURGH. 

SESSION   L. — MEETING   V. 
Wednesday,  IZth  March  1889. — Dr  Underbill,  President,  in  the  Chair. 

I.  The  President  showed  TWIN  placenta. 

II.  Vr  Halliday  Groom  showed — (1),  A  large  ovarian  tumour, 
showing  a  solid  lump  which  had  lain  close  to  liver,  and  rendered 
diagnosis  somewhat  difficult ;  (2),  small  ovarian  tumour  which 
complicated  labour;  (3),  cystic  ovaries  with  occluded  tubes 
from  a  case  where  pelvic  pain  and  consequent  bad  health  existed 
for  fifteen  years ;  (4),  two  ovaries  from  a  case  of  ovaritis,  long- 
standing, traceable  in  all  probability  to  measles. 

III.  Dr  Halliday  Groom  read  his  paper  on  an  analysis  of 
one  hundred  and  twenty-eight  completed  cases  of  abdominal 
SECTION,  which  appeared  at  page  1010  of  this  Journal. 

Professor  Simpson  thought  Dr  Croom  was  to  be  heartily  con- 
gratulated on  the  success  attendant  on  his  interesting  series  of 
laparotomies,  and  the  observations  with  which  he  had  accom- 
panied the  recital  of  some  of  his  cases  made  his  contribution  one 
of  very  great  value.  The  cases  of  tubercular  peritonitis  were 
specially  interesting,  because  experience  in  regard  to  them  was 
only  gradually  accumulating.  He  (Professor  Simpson)  had  met 
it  in  one  case  where  the  diagnosis  had  been  formed  that  the  fluid 
was  peritoneal,  and  when  an  exploratory  incision  was  made,  with 

^  "  Report  from  Select  Committee  on  Habitual  Drunkards,  together  with  the 
Proceedings  of  the  Committee,  with  Minutes  of  Evidence,  ordered  by  House  of 
Commons  to  be  printed  June  13th,  1872."  See  evidence  given  on  March  19th, 
pp.  48-57. 


1144  MEETINGS   OF   SOCIETIES.  [jUNE 

the  view  of  ascertaining  if  it  was  associated  with  any  removable 
cause,  the  peritoneum  was  found  to  be  studded  with  tubercles. 
The  cavity  was  cleared  out,  and  the  patient  recovered  well ;  but 
her  history  after  leaving  the  hospital  had  not  been  traced.  It  was 
supposed  that  fluid  would  re-accumulate.  With  regard  to  the 
cases  of  ovariotomy  that  had  been  followed  by  death  from  fatty 
heart,  he  (Professor  Simpson)  would  like  to  know  if  there  had 
been  any  peritoneal  inflammation  found  on  post-mortem  examina- 
tion. In  the  only  fatal  ovariotomy  that  had  occurred  this  last 
year  in  the  Buchanan  Ward  the  patient  had  fatty  heart,  but  there 
was  also  quite  distinct  peritonitis.  Yet  the  operation  had  been 
an  easy  one,  and  carried  out  with  just  such  precautions  as  Dr 
Groom  had  described.  In  addition  to  the  elements  of  safety 
enumerated  by  Dr  Groom,  he  (Professor  Simpson)  would  add 
rapidity  of  operation,  so  far  as  rapidity  was  consistent  with  due 
attention  to  the  free  cleansing  of  the  peritoneal  cavity.  As  to  the 
rarity  of  pyosalpinx,  his  experience  corresponded  with  that  of 
Dr  Groom. 

Dr  Berry  Hart  congratulated  Dr  Halliday  Groom  on  his  success. 
The  most  interesting  cases  were  those  of  tubercular  peritonitis, 
where  the  results  of  abdominal  section  were  so  gratifying.  The 
pathology  of  these  was  exceedingly  puzzling  in  our  present  state  of 
knowledge. 

Dr  Brewis  had  great  pleasure  in  congratulating  Dr  Groom  on 
his  excellent  results.  With  regard  to  the  remote  effects  in  cases 
where  the  uterine  appendages  have  been  removed  for  disease,  and 
to  which  Dr  Groom  alluded,  Dr  Brewis  is  of  opinion  that  in  the 
majority  of  cases  they  are  most  satisfactory.  The  pain  disappears 
in  most  cases  as  soon  as  the  patient  recovers  from  the  operation, 
although  in  some  instances  it  is  not  got  rid  of  for  months.  All, 
however,  in  Dr  Brewis's  experience  are  freed  from  it  sooner  or 
later. 

Dr  L.  S.  MMurtry,  of  Kentucky,  U.S.A.,  said, — Mr  President,  I 
listened  with  great  interest  to  the  valuable  paper  of  Dr  Groom, 
which,  comprising  as  it  does  such  a  variety  and  extent  of  work,  is 
an  important  contribution  to  abdominal  surgery.  The  care  and 
skill  with  which  the  work  has  been  executed  is  attested  by  the 
admirable  results  achieved.  In  that  portion  of  Dr  Groom's  paper 
treating  of  the  technique  of  abdominal  section,  I  was  pleased  to 
note  his  commendation  of  the  drainage-tube.  As  my  own  experi- 
ence increases,  I  am  led  more  frequently  to  employ  drainage.  A 
small  glass  tube  passed  through  the  lower  angle  of  the  wound, 
properly  dressed  and  frequently  cleansed,  does  not  appreciably 
complicate  the  operation,  and  will  often  secure  easy  progress  to 
recovery  in  otherwise  doubtful  and  fatal  cases.  A  little  sentinel, 
it  stands  at  the  opening  and  tells  of  the  progress  of  events  within. 
It  is  a  faithful  index  as  to  haemorrhage  and  other  intra-abdominal 
complications,  and  furnishes  ready  access  to  the  parts  involved. 


1889.]  OBSTETRICAL   SOCIETY   OF   EDINBURGH.  1145 

The  opening  quickly  closes  after  the  tube  is  removed.  That  such 
a  series  of  abdominal  sections  should  contain  so  few  cases  of  pyo- 
salpinx  is  very  exceptional,  and  is  doubtless  due,  as  both  Dr  Groom 
and  Professor  Simpson  have  stated,  to  the  comparative  rarity  of 
specific  disease  in  Edinburgh.  In  the  United  States  of  America 
this  condition  is  very  common,  and  the  cases  present  the  greatest 
difficulties  in  the  operation.  Adhesions  are  extensive,  the  tissues 
involved  break  down  under  the  surgeon's  touch,  and  pour  great 
quantities  of  foul  pus  into  the  peritoneum.  When  the  diseased 
tissues  are  removed  and  the  abdomen  thoroughly  cleansed  and 
drained, ,  the  results  are  eminently  satisfactory.  The  cases  of 
encysted  dropsy  from  tubercular  peritonitis  are  both  interesting 
and  instructive.  I  do  not  believe  it  is  possible  in  many  instances 
to  differentiate  in  diagnosis  between  encysted  dropsy  of  the  peri- 
toneum and  ovarian  cyst.  Indeed,  the  physical  signs  are  identical. 
This  subject  at  once  recalls  to  mind  the  historic  case  reported  by 
Sir  Spencer  Wells,  in  which  he  found  the  peritoneum  teeming 
with  miliary  tubercles,  and  twenty-two  years  afterward  reports 
the  woman  in  good  health.  Dr  Ely  van  de  Walker  of  Syracuse, 
New  York,  has  reported  a  similar  case  several  years  after  the 
operation,  the  woman  being  in  ruddy  health.  Almost  two 
years  ago  I  operated  upon  a  lady  past  60  years  of  age.  She  was 
emaciated,  bed-fast,  and  rapidly  failing.  The  peritoneum  was 
studded  with  myriads  of  tubercles.  She  made  a  quick  recovery, 
rapidly  regained  her  flesh  and  strength,  and  now,  almost  two  years 
after  the  operation,  is  in  excellent  health  and  free  from  any  symp- 
tom of  abdominal  disease.  In  all  these  cases  the  operation  has 
been  done  after  a  diagnosis  of  ovarian  cystoma.  Some  operators 
have  dusted  over  the  infiltrated  peritoneum  with  iodoform ;  others 
have  applied  various  antiseptic  solutions.  It  seems  immaterial 
as  to  local  applications,  so  the  peritoneum  be  evacuated  and 
cleansed.  So  far  as  I  am  aware,  no  explanation  as  to  how  the 
operation  arrests  the  tubercular  process  has  been  made.  It  is  a 
clinical  fact,  however,  attested  and  confirmed  by  accumulating 
experience. 

Dr  Groom  desired  to  thank  the  Fellows  for  the  reception  given 
to  his  paper.  With  regard  to  the  remarks  of  Professor  Simpson 
concerning  the  four  deaths  of  the  first  group,  Dr  Groom  was  of 
opinion  that  there  could  be  no  doubt  with  regard  to  three  of  them 
resulting  from  fatty  heart,  although,  indeed,  post-mortem  examina- 
tion was  only  permitted  in  one.  They  all  died  suddenly,  without 
developing  any  pulse  or  temperature.  The  fourth  death  resulted 
from  perforation  of  the  stomach,  so  far,  at  least,  as  symptoms  with- 
out a  post-mortem  examination  bore  this  out.  He  was  glad  to 
know  that  Professor  Simpson's  experience  coincided  with  his  own 
as  to  the  rarity  of  pyo-salpinx.  He  was  not  quite  sure  that 
rapidity  of  operation  was  so  great  a  factor  in  successful  operation 
as  Professor  Simpson  claimed  it  to  be,  and  certainly  his  experience 

EDINBURGH   MED.    JOUEN.,    VOL.    XXXIV. — NO.    XII.  7  F 


1146  MEETINGS   OF   SOCIETIES.  [jUNE 

was  that  death  occurred  more  often  in  the  easy  cases  than  the 
severe  ones.  He  believed  that  in  many  cases  it  was  absolutely 
impossible  to  diagnose  an  encysted  hydro-peritoneum  from  an 
ovarian  tumour.  Dr  Hart's  suggestion  of  drying  the  peritoneum 
and  dusting  it  with  iodoform  in  cases  of  tubercular  peritonitis 
would  probably  be  as  successful  as  any  other  method.  The  whole 
subject  was  a  difficult  one.  He  was  glad  to  hear  that  Dr  Hart 
agreed  with  him  as  to  the  value  of  a  drainage-tube.  He  thanked 
Dr  Brewis  for  his  remarks,  and  quite  agreed  with  him  in  what  he 
said  with  regard  to  the  removal  of  the  appendages  in  salpingo- 
ovaritis.  To  Dr  M'Murtry  he  was  obliged  for  his  valuable  criti- 
cism ;  and  it  gave  him  pleasure  to  know  that  his  views  so  closely 
coincided  with  his  own. 

IV.  Dr  Berry   Hart    read   his   paper   entitled   is    the    pubic 

SEGMENT   DKAWN   UP   DURING  LABOUR  ? 

After  remarks  by  Dr  Symington,  Dr  Freeland  Barbour,  Professor 
Simpson,  and  Dr  P.  A.  Young,  Dr  Berry  Hart  said  that  Dr 
Symington's  error  in  regard  to  the  drawing  up  of  the  pubic  seg- 
ment was  evident,  as  he  had  given  his  opinion  without  full  con- 
sideration of  all  the  material. 


ROYAL  MEDICAL  SOCIETY. 


In  accordance  with  the  wishes  of  many  members,  it  was  deter- 
mined to  institute  Clinical  Meetings  during  the  Summer  Session 
for  the  exhibition  of  pathological  specimens  and  the  reading  and 
free  discussion  of  communications  and  medical  subjects  generally. 
The  first  meeting  was  held  8  th  May. 

H.  H.  Littlejohn,  M.B.,  showed — (1.)  Four  stomachs  :  one  from 
a  man  who  committed  suicide  by  swallowing  some  A.  B.  C.  lini- 
ment ;  another  from  a  woman  who  was  accidentally  poisoned  by  a 
dose  of  Bow's  liniment;  another  exhibiting  acute  gastritis  ;  another 
from  an  infant  exhibiting  post-mortem  digestion.  (2.)  An  aorta 
with  three  axeurismal  dilatations  on  it.  The  patient  died  from 
the  rupture  of  a  large  thoracic  aneurism,  which  had  eaten  into  the 
vertebral  column,  almost  destroying  the  bodies  of  three  vertebra3. 
Lower  down  was  another  smaller  aneurism,  which  had  also  eaten 
into  the  spine.  The  third  aneurism  was  situated  immediately 
above  the  aortic  valves.  (3.)  A  carotid  artery  with  a  rupture 
of  THE  INTERNAL  COAT,  from  a  case  of  suicide  by  hanging.  (4.)  A 
portion  of  parietal  bone,  exhibiting  a  rough  uneven  depression, 
apparently  the  site  of  an  old  ulcer.  (5.)  Two  preparations  of 
RUPTURED  BLADDER.     Both  were  the  result  of  external  violence. 

B.  Muir,  M.B.,  communicated  the  case  of  a  male  patient,  44, 
admitted  to  Ward  XXIIL,  Edinburgh  Eoyal  Infirmary,  on  26th 
April  1889,  complaining  of  pain  in  the  left  side  and  difficulty  in 
breathing  of  three  days'  duration.     The  history  presented  nothing 


1889.]  ROYAL   MEDICAL   SOCIETY.  1147 

beyond  that  of  an  ordinary  pleurisy.  There,  however,  had  been 
no  exposure  to  cold,  and  on  the  previous  night  there  had  been 
slight  delirium.  Patient  was  somewhat  thin,  pale,  and  emaciated. 
Temperature,  101°"4  F.  The  physical  signs  were  those  of  pleurisy 
on  the  left  side,  with  slight  effusion  and  pneumonic  complication. 
Pulse  rapid,  irregular,  and  of  poor  tension.     Urine  was  normal. 

A2oril  27. — Much  better,  but  slightly  off  his  head  at  night. 
Temperature,  101°-2  F. 

April  28. — Temperature  at  4  p.m.,  104°  F.  Decidedly  worse, 
with  signs  of  consolidation  and  oedema  over  all  left  lung.  Patient 
unconscious.  At  7  p.m.  paralysis  of  left  side,  including  the  facial 
muscles,  was  noted ;  the  left  pupil  was  dilated  and  insensible,  and 
both  conjunctivae  injected  and  slightly  opaque  in  the  lower  part. 
The  head  was  persistently  turned  to  the  right. 

April  29. — Patient  died  at  2.45  a.m.,  having  shown  no  twitchings 
or  convulsions,  with  temperature  105°'2  F. 

Post-Mortem. — The  presence  of  pus  in  the  pleura,  etc.,  sub- 
stantiated the  diagnosis  of  thoracic  conditions.  The  whole  surface 
of  the  brain  was  bathed  with  greenish  pus,  but  most  markedly  so 
at  the  optic  chiasma.  The  substance  of  the  brain  showed  no 
haemorrhage  or  other  lesion  to  account  for  the  left-sided  paralysis, 
save  distension  of  the  vessels  of  the  right  internal  capsule. 

B.  A.  Fleming,  M.B.,  communicated  the  case  of  a  domestic 
servant,  22,  admitted  to  Ward  XXX.  on  April  28,  1889.  For  ten 
days  she  had  been  suffering  from  a  quinsy  throat,  and  three  days 
before  admission  she  was  unable  to  swallow  or  to  unclench  her 
jaws.  The  day  before  admission  she  developed  attacks  of  dyspnoea, 
and  was  unable  to  articulate.  On  forcing  open  the  mouth  with  a 
gag  no  ulceration  or  cedema  was  seen  in  throat  or  vocal  cords. 
The  tongue  was  furred,  breath  foetid,  and  a  small  quantity  of 
viscid  yellow  sputum  was  coughed  up  with  diiSculty  at  intervals. 
Examination  of  the  chest  revealed  coarse  rales,  loud  rhonchi  and 
dulness  over  the  left  base  and  at  apices.  The  glands  on  the  left 
side  of  the  neck  were  swollen.  Treatment  included  exhibition  of 
apomorphine,  nutritive  enemata,  digitalis,  bromide  of  potash,  and 
nitrite  of  amyl  for  the  dyspnoeic  attacks.  On  pressing  over  the 
hysterogenetic  spots  opisthotonos  was  simulated.  Temperature 
on  admission,  103°  F.,  fell  slightly,  and  patient  died  fourteen  hours 
after  admission  in  an  attack  of  dyspnoea.  On  post-mortem 
examination  all  that  was  revealed  was  foetid  bronchitis,  a  pneu- 
monic patch  at  left  base,  and  a  very  congested  condition  of  brain 
and  medulla. 

H.  H.  Littlejohn,  31. B.,  communicated  the  following  case  : — Mrs 
L.,  who  had  been  delivered  of  twins  three  weeks  previously,  and 
who  was  seen  alive  and  well  at  4  p.m.,  was  found  three  hours  later 
on  the  same  day  lying  dead  with  the  left  side  of  her  head  and  face 
resting  against  the  bars  of  the  fireplace.  The  skin  over  these  parts 
was  burnt  and  charred,  and  bone  was  exposed  to  the  extent  of  a 
crown-piece  in  the  temporal  region.     In  removing  the  skull-cap 


1148  MEETINGS   OF   SOCIETIES.  [jUNE 

the  skin  crumbled  away,  but  the  bone  appeared  not  to  be  charred, 
and  no  fracture  was  to  be  seen.  A  large  clot  of  blood — 4"  in 
length,  2''  in  breadth,  1^"  in  thickness — of  a  chocolate  colour  was 
found  lying  between  the  bone  and  dura  mater  in  the  left  temporal 
and  frontal  regions.  The  brain  showed  no  congestion  or  other 
special  feature,  such  as  haemorrhage  or  embolism,  and  no  disease 
or  rupture  of  external  vessels  could  be  seen.  The  appearances 
over  the  rest  of  the  body  were  such  as  might  be  expected  after 
recent  delivery,  and  there  were  no  marks  of  injury.  Various 
theories  as  to  the  cause  of  death  and  the  sequence  of  events,  as 
well  as  the  medico-legal  aspects  of  the  case,  were  discussed. 

May  15tJi. — H.  IT.  Littlejohn,  M.B.,  showed  the  following  patho- 
logical specimens : — (1.)  Kuptuue  of  aorta  :  a  dissecting  aneurism 
formed  in  the  first  part  of  the  arch  and  opened  externally  into  the 
pericardium,  just  at  the  juncture  of  the  aorta  with  the  left 
ventricle.  (2.)  A  stomach  showing  two  typical  chronic  ulcers, 
one  of  whicli  by  perforation  had  caused  death. 

R.  E.  Horslcy,  M.B.,  by  permission  of  Dr  M'Bride,  showed  speci- 
mens of  GROWTH  removed  from  the  base  of  the  tongue  and  anterior 
surface  of  the  epiglottis.  They  were  formed  by  hypertrophy  of 
the  adenoid  tissue  which  is  normally  present  in  small  quantity  in 
these  situations.  The  signs  and  symptoms  of  the  condition,  in- 
cluding difficulty  in  deglutition  and  prolonged  speaking,  constant 
hawking  from  the  sensation  of  a  lump  in  the  throat,  etc.,  were 
described,  with  a  reference  to  Dr  M'Bride's  views  expressed  in  a 
paper  on  its  supposed  relation  to  globus  hystericus.  The  treat- 
ment by  deobstruents  and  caustics,  both  actual  and  potential,  was 
described. 

E.  C.  Carter,  M.B.,  communicated  the  case  of  a  coachman,  41, 
admitted  to  Ward  XXIX.,  Edinburgh  Eoyal  Infirmary,  under  Dr 
Muirhead's  care,  complaining  of  vomiting  brown  material,  inability 
to  retain  food,  and  pain  in  the  course  of  the  oesophagus.  For 
three  months  patient  had  been  troubled  witli  dyspepsia  and  vomit- 
ing, and  in  spite  of  careful  dieting  and  treatment  had  not  im- 
proved, and  had  lost  a  great  deal  of  weight.  Bowels  had  generally 
been  costive  with  occasional  melsena.  The  abdomen  revealed  no 
tumour,  but  there  was  tenderness  on  pressure  in  the  centre  of  epi- 
gastrium. The  liver  dulness  was  much  diminished  (owing,  prob- 
ably, to  slipping  up  of  a  coil  of  bowel)  and  the  spleen  enlarged. 
The  matter  which  patient  brought  up  in  mouthfuls  was  of  a 
turbid  brown  appearance  and  contained  blood.  Diagnosis,  at 
first,  lay  between — (1),  cirrhosis  of  liver  and  bleeding  from  stomach 
from  backward  pressure  ;  (2),  malignant  disease  of  stomach ;  (3),  a 
functional  disorder.  The  first  was  excluded  by  the  man's  good 
character  and  the  real  size  of  the  liver,  subsequently  found  normal. 
The  second  was  negatived  by  absence  of  tumour  and  character  of 
the  dyspepsia.  On  testing  the  pure  gastric  contents  the  acidity 
was  found  greatly  increased  (8*5  per  mille  to  10-5  per  mille  as  oxalic 


1889.]  ROYAL   MEDICAL   SOCIETY.  1149 

acid)  and  the  presence  of  HCl  shown  by  the  vanillin-phloro- 
gluein  test.  The  attacks  of  vomiting  returned  several  times,  and 
on  each  occasion  were  relieved  by  washing  out  the  stomach,  which 
contained  a  large  quantity  of  brownish  fluid.  The  urine  passed 
during  the  attacks  was  alkaline.  The  diagnosis  was  paroxysmal 
over-acidity,  and  treatment  consisted  in  the  regular  administration 
of  alkalies,  regular  washing  out,  and  a  heavy  meat  diet,  which 
resulted  in  a  gain  of  8^  lbs.  weight  in  a  fortnight. 


|3avt  dTouvtt), 


PERISCOPE. 

MONTHLY  REPORT  ON  THE  PROGRESS  OF  THERAPEUTICS. 

By  William  Craig,  M.D.,  F.E.S.E,,  Lecturer  on  Materia  Medica,  Edinburgh 
School  of  Medicine,  etc.,  etc, 

Hyoscin  in  Insanity. — In  the  British  Medical  Journal  of  27th 
April,  Dr  Thomas  Draper  recommends  the  subcutaneous  injection 
of  hyoscin  as  "a  safe,  certain,  and  rapid  sedative,  unattended  in  the 
vast  majority  of  instances  by  any  unpleasant  results."  He  praises 
it  as  "  a  remedy  for  controlling  paroxysms  of  furious  excitement 
and  turbulent  maniacal  outbreaks."  He  says  it  does  not  cause 
dryness  of  the  mouth,  like  hyoscyamine.  He  always  administers 
it  hypodermically,  beginning  with  a  dose  of  lio  grain,  and  increases 
it  rapidly  to  -xls  grain  if  necessary. 

The  Physiological  Effects  of  Antipyrin. — Messrs  Crolas  and 
Hugounenq  report,  in  the  Lyon  Medical  for  3rd  March  1889,  a 
series  of  experiments  made  to  determine  the  physiological  effects 
of  antipyrin,  their  Research  being  directed  towards  the  determina- 
tion of  the  influence  of  antipyrin  on  the  number  of  red  corpuscles, 
on  the  variations  in  volume  of  the  urine,  urea,  and  the  actual 
amount  of  phosphoric  acid,  and  on  determining  the  toxic  dose  of 
antipyrin.  These  experiments  seem  to  warrant  the  conclusion 
that  in  the  normal  state  of  the  dog,  doses  of  from  45  to  150  grains 
of  antipyrin,  continued  during  forty  days,  do  not  appear  to  sen- 
sibly diminish  the  number  of  the  blood  corpuscles,  while  spectro- 
scopic examination  in  no  case  revealed  the  presence  of  metlioe- 
moglobin  in  the  blood.  Their  experiments  under  the  second 
heading  seem  to  indicate  that  antipyrin  does  not  diminish  the 
quantity  of  urine  excreted  in  twenty-four  hours,  while  their  experi- 
ments as  to  the  influence  of  antipyrin  on  the  urea  are  not 
thoroughly  concordant.  It  would  seem  that  the  urea,  so  far  from 
diminishing  under  the  influence  of  antipyrin,  is  actually  increased. 
Phosphoric  acid,  which  might  be  regarded  as  measuring  the  in- 
tensity of  phenomena  of  denutrition,  does  not  appear  to  be  subject 
to  notable  variations,  a  fact  which  would  seem  worthy  of  attract- 
ing the  attention  of  clinicians.     As  regards  the  toxicity  of  anti- 


1150  PERISCOPE.  [JUNE 

pyrin,  their  experiments  seem  to  show  that  doses  of  from  75  to 
150  grains  of  antipyrin  may  be  given  for  fifty-two  days  at  a  time 
without  producing  any  symptoms  of  poisoning.  In  attempting 
to  determine  the  toxic  dose,  the  authors  gave  at  one  time  150 
grains,  at  another  300  grains, —  a  quantity  corresponding  to  1800 
grains  for  a  man, — and  yet  no  marked  effects  were  observed. — 
Therapeutic  Gazette,  April  1889. 

Some  Experiments  with  Sulphonal. — Until  quite  recently 
the  reports  of  the  results  of  the  use  of  sulphonal,  the  new  hyp- 
notic, have  been  decidedly  in  its  favour.  Of  late,  however,  some 
accounts  have  come  from  abroad  which  indicate  that  it  is  not  so 
harmless  as  was  at  first  asserted.  This  drug  seems  to  be  of  so 
much  value,  that  exact  Icnowledge  of  its  effects  is  quite  desirable. 
Its  high  price  has  probably  prevented  a  very  extensive  use  of  it, 
and  reports  of  its  effects  have  so  far  been  somewhat  meagre. 
Dr  C.  M.  Eexford's  experience  with  sulphonal  seems  to  show  that 
it  is  about  as  well  adapted  to  one  class  of  cases  as  another,  and 
that  the  only  reason  for  expecting  a  failure  in  any  given  case  is 
the  presence  of  extreme  pain  {Medical  Becord,  March  30,  1889). 
The  first  patient  upon  whom  its  effects  were  observed  was  a  woman 
who,  from  long-continued  nervous  strain,  fell  into  a  state  of  com- 
plete prostration,  attended  by  intense  cerebral  congestion,  non- 
inflammatory in  character,  with  violent  and  constant  headache, 
hallucinations,  and  finally  delirium  of  a  low  type,  lasting  for 
months.  This  condition  could  only  be  controlled  by  opiates ;  and 
upon  their  withdrawal,  which  improvement  made  possible,  it  was 
succeeded  by  sleeplessness  and  much  pain  in  the  head.  At  this 
time  sulphonal  was  put  on  the  market.  The  first  dose  gave  the 
patient  a  night  of  natural  sleep,  and  the  head  felt  much  better  the 
next  day.  No  more  perfect  result  could  be  desired  than  the  drug 
produced  in  this  case.  A  dose  of  20  to  30  grains  always  produces 
sleep,  relieves  the  distress  in  the  head,  and  leaves  no  bad  effect 
whatever.  It  has  only  been  necessary  to  use  the  drug  occasionally, 
and  nothing  like  a  habit  has  been  formed.  The  medicine  was 
employed  in  a  recent  case  of  pneumonia.  The  attack  was  not 
severe ;  but  the  patient,  a  feeble  woman,  past  middle  life,  was  an 
extremely  nervous  and  difficult  one.  Great  depression  of  the 
nervous  system  came  on  with  persistent  sleeplessness,  which  proved 
wholly  refractory  to  ordinary  sedatives.  A  dose  of  10  grains  of 
sulphonal  was  given.  No  effect  besides  greater  restlessness  was 
produced  for  four  hours.  Then  profound  sleep  ensued,  which  per- 
sisted for  twenty-four  hours.  During  this  time  it  was  difficult  to 
rouse  her  enough  to  take  nourishment.  No  other  ill  result  followed, 
nor  did  the  insomnia  return.  The  depth  of  the  stupor  produced 
by  the  small  dose  employed  was  such  as  to  make  the  result  of  a 
larger  dose  seem  rather  doubtful.  This  patient  has  a  weak  heart, 
sometimes  intermitting,  but  it  seemed  not  to  be  affected  by  the 
drug.     Another  case  was  one  suffering  from  chronic  neuritis.     This 


1889.]  MONTHLY   REPORT   ON   THERAPEUTICS.  1151 

patient  when  first  seen  was  extremely  debilitated  by  absence  of 
appetite  and  want  of  sleep.  Fifteen  grains  of  sulphonal  at  bedtime 
acted  very  favourably  for  a  time,  but  finally  failed  to  induce  sleep, 
and  only  caused  great  restlessness  instead.  Finally,  a  second  dose 
of  15  grains  was  given,  four  hours  after  the  first.  The  patient  then 
fell  asleep.  In  the  morning  she  was  unable  to  rise.  She  com- 
plained of  giddiness,  of  being  unable  to  hold  the  head  up,  and 
could  not  stand  or  walk  without  assistance.  There  was  vomiting, 
and  the  stomach  refused  to  retain  food  for  many  hours.  When 
permitted  she  slept  a  troubled,  uneasy  sleep  for  the  whole  day. 
It  was  not  till  the  end  of  three  days  that  she  felt  herself  again. 
This  patient  also  has  a  very  weak  heart,  though  there  is  no  organic 
lesion.  She  is  frequently  faint,  or  is  obliged  to  lie  down,  because 
the  heart  acts  badly.  While  under  the  influence  of  the  medicine, 
as  related,  the  heart  symptoms  seemed  to  be  made  somewhat 
worse,  but  not  notably  so.  In  the  considerable  number  of  other 
cases  in  which  this  remedy  has  been  employed,  it  has  acted  in  the 
main  favourably.  These  have  been  cases  of  nervous  insomnia,  and 
they  have  all  yielded  without  any  difficulty  and  with  no  untoward 
result.  The  experience  of  the  writer  seems  to  indicate  that 
sulphonal  is  a  valuable  medicine,  but  that  it  has  its  limitations. 
It  is  easy  to  take,  it  does  not  often  irritate  the  stomach  or  produce 
ill  effects ;  but  it  may  fail  to  act  as  expected,  and  in  some  instances 
it  may  produce  extremely  disagreeable  results.  The  dose  which 
was  at  first  recommended,  of  30  to  60  grains,  is  too  large  to  com- 
mence with.  It  is  unsafe  to  give  more  than  10  grains  as  an  initial 
dose,  and  15  grains  will  prove  a  sufficient  dose  in  the  majority  of 
cases. — Therapeutic  Gazette,  April  1889. 


MEDICAL  PERISCOPE. 
By  Francis  Troup,  M.D. 

Ccntndhlatt  f.  BaJcter.  lo.  Parasitenhmde,188S,  iv.  Band,  Nos.'16 
to  25. — Dr  F.  Wesener  has  a  series  of  papers  on  the  anti-parasitic 
treatment  of  phthisis,  in  which  he  includes  all  the  literature  that 
has  appeared  on  the  subject  from  the  discovery  of  the  tubercle 
bacillus  up  to  the  end  of  1887.  No  less  than  279  references  arc 
given  to  articles  in  journals,  and  also  to  more  pretentious  works.  A 
reprint  has  been  issued  by  the  Centralhlatt,  and  Dr  Wesener's 
concise  report  will  repay  the  study,  alike  of  those  who  believe  in 
the  utter  malignancy  of  phthisis  and  of  those  who  find  it  a  very 
curable  disease. 

He  says  that  no  other  human  disease  can  boast  of  such  a  rich 
treasury  of  all  possible  proposed  and  tried  remedies  and  modes  of 
treatment  as  consumption. 

It  is  a  commonly  accepted  axiom  that  the  curability  of  a  disease 
is  inversely  proportional  to  the  number  of  medicaments  and  thera- 
peutic measures  which  are  adopted  against  it.     The  medicine-chest 


1152  PERISCOPE.  [JUNE 

of  malaria  consists  principally  of  arsenic  and  quinine ;  of  syphilis, 
of  mercury  and  iodine ;  and  yet  the  treatment  of  both  of  those  mala- 
dies is  as  successful  as  any  of  which  Medicine  can  speak.  On  the 
otlier  hand,  the  more  drugs  and  therapeutic  measures  which  are 
and  yet  will  be  employed  against  a  disease,  the  more  justifiable  is 
the  conclusion  that  no  really  efficacious  remedy  has  yet  been  dis- 
covered for  it.  This  is  the  case  with  phthisis.  Iimumerable  means 
and  methods  of  cure  are  praised,  and  every  year  sees  new  proposals 
brought  forward,  or  old  ones  are  again  resuscitated,  and  yet  the 
problem  of  the  healing  of  consumption  waits,  and  will  wait  for  long, 
for  its  solution.  Certainly  we  know  means  which  favourably  influ- 
ence the  course  of  the  disease ;  we  frequently  observe  that  careful 
and  suitable  treatment  brings  it  to  a  shorter  or  longer  period  of 
inaction,  and  it  is  no  longer  doubtful  that  cases  do  sometimes 
recover  completely.  It  is  just  as  certain,  however,  that  no  specific 
is  yet  known  which  can,  in  the  majority  of  cases,  bring  this  about 
with  any  certainty. 

Another  reason  for  the  multiplicity  of  cures  for  consumption  may 
be  found  in  the  diverse  and  contradictory  views  which  formerly 
obtained  as  to  its  aetiology  and  essence.  The  value  of  an  early 
prophylaxis  and  properly  adapted  symptomatic  treatment  were 
recognised,  but  opinions  varied  much  as  to  what  was  demanded  by 
the  causal  indication  and  the  indication  of  the  disease.  The  man 
who  believed  it  to  be  essentially  an  inflammation  employed  anti- 
phlogistic therapy ;  he  who  thought  that  insuflicient  entrance  of  air 
to  the  lung  and  its  consequent  imperfect  inflation  were  the  chief 
setiological  moments  recommended  pneumo-therapy  and  lung  gym- 
nastics ;  and  so  on  until  the  discovery  of  the  tubercle  bacillus 
brought  something  like  definite  clearness  into  the  aetiology,  and 
therapeutics  gained  so  far  that  it  seemed  incontrovertible  that  a 
real  healing  of  consumption  could  only  be  obtained  by  an  anti- 
bacterial treatment.  This  anti-parasitic  method  must  naturally  fall 
tinder  two  heads :  either  to  work  directly  on  the  parasites  and 
destroy  them,  or  to  render  the  medium  in  which  they  flourish  un- 
serviceable. In  the  living  organism  the  body  cells  must  be  so 
strengthened  in  their  life  energy  as  to  overcome  and  render  the 
invading  parasites  harmless.  Various  therapeutic  methods  may  be 
followed  in  this  direction  :  pneumato-therapy,  climato-therapy,  lung 
gymnastics,  hydro-therapeutics,  and  special  dietetic  treatment,  as 
cod-liver  oil,  milk,  glycerine,  and  over-nourishment.  The  direct 
anti-parasitic  treatment  tries  to  destroy  the  bacilli  by  medicamenta- 
tion  which  may  prove  poisonous  to  them.  Synoptically  Dr 
Wesener  divides  his  report  into  a  number  of  chapters,  according 
to  the  manner  and  kind  of  such  medicaments  : — The  Treatment  per 
Os;  Per  and  Sub-cutaneous  Treatment ;  Inhalations;  Treatment  per 
Kectum  ;  Intraparenchymatous  Treatment ;  Lung  Surgery  proper. 

1.  Internal  Phthiseothcrapj. — (1)  Arsenic,  (2)  phosphorus,  (3) 
antimony,  (4)  iodine  in  form  of  iodoform,  (5)  mercury,  (6)  sul- 
phur, (7)  aluminium,  (8)  peroxide  of  hydrogen,  (9)  turpentine  and 


1889.]  MEDICAL  PERISCOPE.  1153 

its  derivatives,  (10)  creosote,  (11)  tannin,  (12)  salicine,  (13)  vege- 
table substances — Verbascum  thapsus,  (Enanthe  phellandrium  and 
eucalyptus  honey. 

2.  Per  and  Suh-cutaneous  Therapy. — Eucalyptol,  turpentine, 
phenic  acid,  iodoform. 

3.  Inhalation  Treatment. — Pneumatic  differentiation,  phenol, 
creosote,  thymol,  iodine,  carbolic  acid,  boracic  acid,  alkalies,  bin- 
iodide  and  bichloride  of  mercury,  inhalations  of  oxygen,  nitrogen, 
chloride  of  sodium,  coal  dust,  preparations  of  iodine,  chiefly  iodo- 
form, preparations  of  sulphur,  hydrofluoric  acid,  turpentine,  menthol 
and  eucalyptol,  tar,  picric  acid,  anilin,  naphtha,  bacterium  termo. 

3.  Treatment  per  Bectmn. — No  less  than  eighty  references  are 
given  under  this  head.  Bergeon  employed  a  mixture  of  carbonic 
acid  and  sulphuretted  hydrogen  in  enemata.  This  much-vaunted 
cure  by  Bergeon  himself  at  the  congresses  of  Toulouse  and  Weis- 
baden,  was  said  only  to  better,  not  to  heal.  If  it  cannot  do  this 
latter,  less  disagreeable  and  less  dangerous  methods  of  bringing 
about  improvement  are  known  to  therapeutics,  and  should  preferably 
be  used. 

4.  Intraparenchymatous  Injections. — Here  the  medicine  is  injected 
into  the  diseased  lung.  Among  remedies  used  are  sublimate, 
Lugol's  solution,  creosote  in  alcohol,  iodoform  dissolved  in  olive  oil 
or  ether,  carbolic  acid  and  iodoform  in  glycerine  and  diluted  spirit, 
anilin,  turpentine,  lactic  acid,  chloride  of  zinc. 

5.  Operative  Treatment  of  Caverns. — Hosier  thinks  they  should 
not  be  touched.  Bull  thinks  that,  as  a  rule,  such  cavities  are  not 
fitted  for  operative  treatment.  De  C^renville  has  treated  three 
cases  of  cavity  by  incision,  resection  of  ribs,  and  tamponade  of  the 
hole  with  wad  and  iodoform.     The  patients  all  died. 

Neve,  in  a  patient  who  presented  the  physical  signs  of  a  cavity 
in  the  right  upper  lobe — elastic  fibres  and  bacilli  in  the  sputa — 
while  the  right  base  and  the  greater  part  of  the  left  lung  were 
sound  and  only  a  slight  consolidation  of  the  left  apex.  The  cavity 
was  opened  and  drained,  and  washed  out  daily  with  sublimate 
solution  and  eucalyptus  oil ;  besides,  he  inhaled  creosote  and 
eucalyptus.  Expectoration  diminished,  strength  improved,  but  the 
left  apex  did  not  clear.  Patient  was  alive  at  date  of  publication. 
Godlee  treated  a  case  of  basal  cavern,  but  patient  soon  died  of 
tuberculosis. 

As  a  curiosity,  Adams'  proposal  may  be  mentioned.  He  had  seen 
a  case  of  phthisis  improve  after  pneumo-thorax  had  taken  place,  and 
seriously  offers  for  consideration  the  propriety  of  causing  an  artificial 
pneumo-thorax.  Wesener  remarks  that  the  way  in  which  Adams 
explains  the  good  effect  of  the  pneumo-thorax  is  as  fantastic  as  his 
therapeutics. 

Lung  resection  in  man  has  not  yet  been  the  subject  of  any 
scientific  publication,  and  will  probably  never  become  a  branch  of 
phthiseotherapy. 

EDINBURGH   MED.   JOURN.,   VOL.   XXXIV. — NO.   XII.  7  G 


1154  PERISCOPE.  [JUNE 

In  conclusion,  Dr  Wesener  gives  a  list  of  thirty-one  text-books, 
monographs,  and  lectures  on  the  antiparasitic  treatment  of  consump- 
tion in  general. 

OCCASIONAL  PERISCOPE  OF  DEEMATOLOGY. 

By  W.  Allan  Jamieson,  M.D.,  F.R.C.P.,  Extra  Physician  for  Diseases  of 
the  Skin,  Edinburgh  Royal  Infirmary ;  Lecturer  on  Diseases  of  the  Skin, 
Edinburgh  School  of  Medicine. 

How  Wheals  are  produced  in  Urticaria. — Jacquet  lays  down 
the  canon,  "that  if  in  the  case  of  one  affected  with  an  acute 
generalized  urticaria  a  part  of  the  body  be  hermetically  protected, 
say  for  instance  the  leg,  the  phenomena  of  nettle-rash — pruritus 
and  elevations — become  sharply  and  entirely  effaced  on  the  limb." 
The  duration  of  the  immunity  has  no  other  limit  than  that  of  the 
application  of  the  protective  medium.  In  the  cases  experimented 
on  by  him,  sheets  of  wadding  kept  in  position  by  a  bandage  were 
employed,  but  he  thinks  it  probable  that  any  similar  method  would 
equally  succeed.  From  this  he  reasons  that  since  in  the  subjects 
of  urticaria  all  protected  portions  of  the  integument  continue 
unaffected,  to  evoke  the  wheal  demands  some  sort  of  excitation  of 
the  skin.  This  may  be  but  slight, — scratching,  the  friction  of  the 
clothes,  contact  with  fresh  air.  Thus  one  is  naturally  led  to 
compare  fictitious  wheals,  or  those  termed  dermographic,  cases 
where  the  skin  reflects  in  relief  pressure  exerted  on  it.  In  these 
latter  cases,  however,  tolerably  energetic  pressure  is  required ;  in 
urticaria  the  excitation  is  much  more  superficial.  There  is  no 
essential  difference,  for  the  vaso-motor  erethism  is  only  more  easily 
awakened  in  the  one.  In  urticaria  there  is,  1st,  a  particular  con- 
dition of  the  cutaneous  vaso-motricity ;  and,  2nd,  a  local  excitation 
which  provokes  the  neuro-paralytic  reaction.  But  the  vaso-motor 
erethism  in  question  is  not  constantly  generalized, — far  from  it,  it 
is  solely  in  acute  and  intense  cases  that  it  exists  everywhere 
and  permanently.  More  commonly  it  is  limited  to  particular 
regions  and  to  certain  periods.  In  a  word  there  are  partial  urti- 
carias, and  such  are  doubtless  the  commonest.  Hence  attempts  to 
induce  dermographism  or  artificial  wheals  may  fail  in  the  case  of 
one  affected  with  urticaria,  though  this  does  not  prove  that  the 
wheal  is  not  the  result  in  all  cases  of  a  local  excitation.  On  the 
other  hand,  Jacquet  affirms  that  every  one  suffering  from  a  gene- 
ralized urticaria  is  always  dermographic. — Annates  de  dermatologie 
et  de  sypMligraphie,  Nos.  8,  9,  1888. 

Verruca  Plana  of  the  Face  in  Youth. — While  verruca 
vulgaris  of  the  hands  and  fingers  in  adolescents  is  common,  and 
verruca  plana  of  the  hand,  face,  neck,  and  chest  both  before  and 
behind  is  not  infrequent  in  the  old,  there  have  only  been  a  few 
cases  recorded  in  which  a  veritable  eruption  of  warts  has  appeared 
nearly  simultaneously  on  different  parts  of  the  body,  more  especially 
on   the   face,   in  persons,  hitherto   exempt.      Besnier    first    drew 


1889.]  PERISCOPE   OF   DERMATOLOGY.  1155 

attention  to  this  variety,  which  forms  elevations  not  rising 
much  above  the  surface,  smaller  and  not  so  deeply  coloured  as 
the  verruca  senilis.  He  believed  that  they  were  met  with 
exclusively  in  the  young.  Thin  recorded  in  1881  an  example  in 
a  woman,  aged  21,  in  which  these  warts  were  very  numerous  on  the 
face,  and  less  so  on  the  backs  of  the  hands.  Darier  now  adds 
another  instance  in  a  woman  aged  25.  They  first  appeared  on  the 
right  cheek  several  months  after  her  first  confinement,  then  the  left 
cheek  was  attacked.  There  were  small  flat  papules,  little  elevated, 
of  a  yellowish  hue,  somewhat  like  caf6  au  lait,  and  sharply  defined 
from  the  rose  colour  of  the  cheeks.  There  was  no  itching.  A 
section  of  one  removed  showed  that  tliey  were  constituted  of  a 
hypertropliy  of  all  the  layers  of  the  epidermis,  with  elongation  of 
the  papillae.  In  opposition  to  Auspitz  and  Thin  he  believes  the 
latter  of  those  alterations  is  the  primary. — Annales  de  dermatologie 
et  de  syphiligraphie,  No.  10,  1888. 

Hydroxylamin. — This  is  a  substance  which  Binz  has  found  to 
possess  powerful  reducing  properties,  and  believes  capable  of 
replacing  pyrogallic  acid  and  chvysarobin  in  therapeutics,  inasmuch 
as  it  has  their  good  qualities  while  it  does  not  stain  the  skin  or 
linen.  Eichhoff  has  tried  it  at  Elberfeld  during  two  months,  and 
has  been  so  satisfied  with  it  that  he  recommends  it  to  the  notice  of 
the  profession  for  more  extended  observation.  It  is  a  toxic  agent 
of  considerable  potency,  and  must  therefore  be  employed  with 
caution.  He  uses  the  hydrochlorate  of  hydroxylamin  in  the  pro- 
portion of  1  in  1000  of  equal  parts  of  spirit  and  glycerine.  After 
the  affected  parts  have  been  washed  with  soft  soap,  some  friction 
being  made  use  of,  the  solution  is  painted  on ;  and  this  is  repeated 
from  three  to  five  times  daily.  Five  cases  of  lupus  were  so  treated, 
with  marked  improvement ;  it  would  be  too  early  to  speak  of  a 
cure.  He  recommends  its  employment  in  psoriasis,  and  in  eczema 
seborrhoeicum.  —  Monatshefte  filr  praktische  Dermatologie,  No.  1, 
1889. 

Tuberculosis  Papillomatosa  Cutis. — D.  P.  C.  Morrow 
describes  the  case  of  an  Italian,  aged  30,  affected  with  a  remarkable 
vegetating  growth  on  the  face.  The  previous  history,  which  was 
incomplete,  showed  that  his  forearm  had  been  amputated  for  a 
disease  of  the  left  wrist,  which  he  was  led  to  regard  as  tubercular 
osteitis.  At  that  time  there  was  a  verrucose  tubercle  on  the  side  of 
the  nose,  but  the  date  of  its  first  appearance  was  uncertain.  During 
convalescence  from  the  operation  the  tubercle  grew  larger,  and 
assumed  more  of  a  papillomatous  condition,  and  similar  lesions 
appeared  on  the  forehead  at  margin  of  hair  and  above  the  left  eye. 
Those  on  the  forehead  subsequently  disappeared,  leaving  a  cicatrix. 
The  lesions  increased  in  extent,  so  that  when  he  came  under  Dr 
Morrow's  treatment  the  entire  nose,  the  cheeks,  the  right  upper 
eyelid,  and  the  upper  lip  were  transformed  into  a  papillomatous 
growth,  deep  red  in  colour  and  resembling  a  cauliflower.     The 


1156  PERISCOPE.  [JUNE 

vegetations  were  not  surrounded  by  an  infiltrated  margin  or 
inflammatory  areola,  but  seemed  to  arise  directly  from  the  healthy 
skin,  the  sound  epidermis  being  continued  partly  up  the  wall  of  the 
papillary  growth.  He  had  an  opportunity  of  watching  the  advance 
of  the  outgrowths  on  the  left  eyelid.  The  lesions  appeared  at 
disseminated  points  as  small,  pinhead  sized  papules,  with  a  large 
base,  upon  apparently  healthy  skin.  As  the  papules  enlarged  the 
epidermis  yielded  in  the  centre,  and  pea-sized  vegetations  sprouted 
forth,  which  coalesced  into  one  mass  by  the  formation  of  fresh 
outgrowths.  The  vegetations  were  very  vascular,  and  bright  or 
deep  red  in  colour.  There  was  considerable  itchiness  and  pain. 
On  the  neck  were  glandular  enlargements,  corresponding  to  the 
gommes  scrofuleuses  or  the  gommes  hiberculeuses  of  French  writers. 
The  general  health  was  good,  and  there  was  no  pulmonary  disease. 
A  microscopic  examination  of  portions  of  the  vegetations  made  by 
Dr  Elliot  showed  the  histological  features  of  a  tubercular  granuloma, 
and  the  presence  of  tubercular  bacilli.  After  comparing  the  clinical 
features  of  the  case  with  the  various  forms  of  tuberculosis  of  the 
skin  and  with  syphilis,  Morrow  concludes  that  it  is  a  cutaneous 
tuberculosis,  basing  his  opinion  on  the  mode  of  origin  and  the 
evolution  of  the  growths,  the  existence  of  tubercular  or  scrofulous 
gummata,  and  the  results  of  microscopic  examination. — Journal  of 
Cutaneous  and  Genito-  Urinary  Diseases,  Oct.  and  Nov.  1888. 

Lupus  of  the  Tongue.  —  According  to  all  the  published 
observations  of  dermatologists,  lupus  has  seemed  to  respect  the 
tongue,  but  Leloir  has  met  with  one  instance  in  which  the  dorsum  of 
this  organ  was  attacked  by  lupus  verrucosus.  The  youthful  patient 
had  presented  lierself  at  his  clinique  for  lupus  vulgaris  of  the  face. 
The  posterior  half  of  the  tongue  was  found  invaded  by  a  genuine 
lupus  verrucosus,  as  confirmed  both  by  histological  examination  and 
by  the  result  of  experimental  inoculations,  and  the  diagnosis  was 
confirmed  by  Bergh,  Unna,  Feulard,  Doutrelepont,  and  others.  The 
epiglottis  and  vocal  cords  were  also  the  seat  of  the  same  form  of 
lupus. — Annates  de  Dermatologie  et  de  Syphiligraphie,  Oct.  1888. 

Pityriasis  Pilaris. — Caesar  Boeck  has  drawn  attention  to  a 
peculiar  form  of  disease,  which  was  originally  described  by  Devergie, 
and  of  which  so  far  only  about  eighteen  cases  have  been  recorded. 
The  complaint  commences  usually  on  the  palms  of  the  hands  or 
soles  as  an  itchy  sensation,  then  red  spots  form,  which  soon  become 
scaly,  and  coalesce  and  advance  over  the  whole  surface  of  the 
localities  named,  till  the  surface  is  covered  with  thick  hard  masses 
of  epidermis.  Cracks  and  fissures  are  apt  to  occur,  which  though 
painful,  seldom  weep.  The  corium  beneath  is  congested,  and  this 
seen  through  the  thick  epidermis  imparts  a  yellow  hue.  The 
process  extends  to  the  sides  of  the  fingers  and  toes,  ending  by  a 
sharply-marked  line  of  demarcation.  The  first  phalanges  of  the 
fingers  on  their  dorsal  aspect  are  peculiarly  aff'ected.  There  is  a 
limited  patch,  corresponding  to  the  part  on  which  the  strongest 


1889.]  PERISCOPE   OF   DERMATOLOGY.  1157 

hairs  grow.  It  is  further  noticeable  that  each  hair  is  surrounded 
by  a  horny  cone  of  epidermis,  penetrating  into  the  skin.  Should 
such  be  extracted,  a  surface  riddled  with  minute  apertures  is  left. 
The  same  epidermic  aggregations  are  found  on  the  back  of  the 
hand  and  on  the  arms.  Near  the  elbow  there  may  be  patches 
closely  resembling  psoriasis,  covered  with  silvery  scales.  On  the 
lower  limbs  the  parts  are  more  uniformly  implicated,  but  there  is 
little  infiltration  of  the  corium.  The  colour  is  pale  chamois  yellow, 
with  a  silvery  glance.  On  the  head  there  may  be  some  ordinary 
pityriasis,  and  on  the  abdomen  the  same  epidermic  accumulations 
round  the  hairs,  and  involving  their  sheaths,  may  occur.  The  nails 
become  thickened  and  furrowed  transversely.  The  inguinal  lym- 
phatic glands  may  enlarge.  Yet  there  is  an  absence  of  marked 
constitutional  symptoms.  In  the  more  severe  instance  of  two 
related  by  Boeck  there  was  considerable  emaciation,  and  a  feeling 
of  indisposition  with  nervous  disturbance.  The  disease  is  serious, 
from  its  irksomeness  and  obstinacy.  It  is  very  capricious,  and 
when  apparently  nearly  cured  may  exhibit  fresh  outbreaks.  It 
may  show  itself,  according  to  Brocq,  from  the  age  of  4  months  to 
54  years.  Men  are  more  apt  to  suffer  than  women.  The  treatment 
consists  in  the  administration  of  arsenic  for  long  periods  and  in  full 
doses.  Cod-liver  oil  is  also  useful.  Externally,  Unna's  glycerine 
jelly  is  most  suitable.  (An  excellent  r^ime  of  our  knowledge  of 
this  complaint,  by  Dr  Brocq,  will  be  found  in  the  Archives  ghierales 
de  MSdecine  for  1884.  In  the  meantime  some  doubt  must  be  felt 
whether  such  cases  are  not  variants  of  ordinary  psoriasis,  commenc- 
ing in  a  special  and  exceptional  manner,  and  involving  the  hair 
sheaths  more  particularly  ;  and  if  it  is  wise  to  add  another  disease 
under  the  name  of  pityriasis  pilaris,  all  the  more  as  the  complaint 
affects  regions  on  which  no  hairs  are  found  primarily  and  most 
severely. — W.  A.  J.) — Monatshefte  fur  'prdktische,  Dermatoloyiej 
No.  3,  1889. 


ilatt  dFiftJ. 


MEDICAL    NEWS. 


CoNGRES  International  de  Therapeutique  et  de  Matiere 
Medicale. — Le  congr^s  aara  lieu  ^  Paris,  du  ler  au  5  aoUt  1889, 
^  I'hotel  des  Socidt^s  savantes,  28,  rue  Serpen te.  Pourront  en  faire 
partie  tons  les  m^decins,  pharmaciens  et  vet^rinaires  qui  auront 
envoyd  leur  adhesion  et  payd  la  cotisation  de  10  francs.  Le 
bureau  du  Comitd  d'organisation  est  ainsi  compost :  MM. 
Moutard-Martin,  president ;  Dujardin-Beaumetz,  vice-president ; 
Constantin  Paul,  secretaire  g^n^i-al ;  P.-Gr.  Bardet,  secretaire  general 
adjoint;  Labb^,  secretaire  de  la  section  de  therapeutique,  et  B,. 
Blondel,  secretaire  de  la  section  de  matiere  medicale.  Le  congr^s 
sera  divise  en  deux  sections:  I'une  de  tMrapeutiqiie,  I'autre  de 


1158  MEDICAL   NEWS.  [jUNE 

matilre  mMicale.  Chacune  des  deux  sections  pourra  d^lib^rer  k 
part  dans  des  salles  s^par^es,  aux  stances  de  la  matinee  consacrees 
aux  questions  particuli^res  laiss^es  au  choix  des  membres  du 
congris ;  les  stances  du  jour  seront  communes  et  r^servees  ^  la  dis- 
cussion des  questions  posees  par  le  Comit4  d'organisation  du 
congr^s.  Fremih'e  question. — "  Des  antithermiques  analgesiques  :  " 
Chimie  et  pharmacologic  de  ces  corps, — action  physiologique  et 
usages  th^rapeutiqes, — lois  qui  peuvent  permettre  d'^tablir  une 
relation  entre  la  fonction  cliimique  et  la  fonction  physiologique. 
(Rapporteur,  M.  Dujardin-Beaumetz.)  Deioxieme  question. — "  Des 
antiseptiques  propres  h  chaque  esp^ce  de  microbes  pathog^nes : " 
Valeur  proportionnelle  des  antiseptiques,  leur  action  speciale, — 
^tude  de  leur  mode  d'absorption  et  des  meilleurs  proc^des  d'ad- 
ministration.  (Rapporteur,  M.  Constantin  Paul.)  Troisieme 
question. — "Des  toniques  du  coeur :  "  Leur  nature, — leurs  actions 
sp^ciales, — valeur  relative  des  plantes  et  de  leurs  principes  actifs, 
alcaloides  et  glucosides.  (Rapporteur,  M.  Bucquoy.)  Quatritme 
question. — "Des  nouvelles  drogues  d'origine  v^g^tale  r^cemment 
introduites  dans  la  th^rapeutique."  (Rapporteur,  M.  Planchon.) 
Cinqui^me  question. — "  Unification  des  poids  et  mesures  employes 
dans  les  formules ;  de  I'utilite  d'une  pharmacop^e  internationale." 
(Rapporteur,  M.  Sliaer,  de  Zurich.)  Les  membres  du  congr^s  qui 
comptent  faire  une  communication  sont  pri^s  d'en  annoncer  le  titre 
au  secretaire  du  comitd  avant  le  15  mai  prochain.  Les  communica- 
tions et  discussions  seront  rdunies  dans  un  volume  qui  sera  imprim^ 
par  les  soins  du  comite  d'organisation  et  sera  adressd  h,  chaque 
adherent.  Une  exposition  de  drogues  simples  se  rapportant  aux 
questions  poshes  par  le  Comitd  aura  lieu  au  siege  du  congr^s 
pendant  la  durde  de  la  session ;  elle  sera  organisde  par  les  soins  de 
MM.  Adrian  et  Blondel.  On  est  prie  d'adresser  toutes  les  adhesions 
ou  communications  au  Dr  Bardet,  secretaire  general  adjoint  du 
comite  d'organisation,  119  bis,  rue  Notre-Dame-des-Champs,  k 
Paris. 

CoNGREs  International  D'Otologie  et  de  Laryngologie 
(Paris,  mars  1889). — Trbs  honor^  Confrere, — Un  Congr^s  inter- 
national d'Otologie  et  de  Laryngologie  aura  lieu  h  Paris,  du  16  au 
21  septembre,  dans  le  palais  du  Trocadero.  Nous  avons  I'lionneur 
de  vous  inviter  a  prendre  part  h  ses  travaux.  Pour  nous  conformer 
aux  traditions  des  precedents  Congr^s  internationaux  d'Otologie  et 
de  Laryngologie,  nous  avons  pense  qu'il  etait  preferable  de  laisser 
k  I'initiative  de  chacun  le  choix  des  sujets  qu'il  se  proposera  de 
traiter,  et  nous  n'avons  mis  k  I'ordre  du  jour  aucune  question. 
Nous  vous  prions  d'adresser,  avant  le  15  juillet,  au  Secretaire  du 
Comite  d'organisation  les  titres  des  communications  que  vous 
voudrez  bien  apporter  au  Congr^s.  Nous  avons  I'esperance  qu'un 
tres  grand  nombre  de  medecins  repondront  a  notre  invitation,  et 
nous  vous  prions  de  faire  connaitre  la  date  de  notre  Congr^s  k 
tous  ceux  de  nos  confreres  de  votre  connaissance  qui  s'interessent 


1889.]  MEDICAL   NEWS— OBITUARY.  1159 

aux  sciences  de  I'Otologie  et  de  la  Laryngologie,  et  qui  n'auraient 
pas  re9U  la  prdsente  communication.  Ceux  dont  vous  voudrez  bien 
nous  faire  connaitre  les  noms  recevront,  dans  le  plus  bref  delai,  les 
documents  pr^paratoires  du  Congr^s.  Une  circulaiie  sera  adressde, 
en  temps  opportun,  h  tous  les  adherents,  afin  de  leur  faire  connaitre 
les  dispositions  prises  par  le  Comit^  d'organisation  pour  donner  au 
Congres  1' importance  scientifique  la  plus  grande,  pour  faciliter  les 
voyages,  et  pour  rendre  k  ses  membres  le  s^jour  de  Paris  aussi 
utile  qu'agrdable.  Le  montant  de  la  cotisation  est  fix^  k  vingt 
francs.  Veuillez  agr^er,  tres  honord  confrere,  I'assurance  de  nos 
sentiments  confraternels.  Le  Comiti  d'organisation:  Professeur 
Duplay,  president ;  Docteur  Gouguenheim,  Docteur  Ladreit  de 
Lacharriere,  vice-presidents ;  Docteur  Loewenberg,  secretaire ;  Doc- 
teurs  Boucheron,  Calmettes,  Garel  (de  Lyon),  Gell^,  Joal,  Lannois 
(de  Lyon),  Meniere,  Miot,  Moure  (de  Bordeaux),  Noquet  (de 
Lille),  Ruault,  Terrier  et  Tillaux,  Membres  du  Comiti. 


OBITUAEY. 


THE  LATE  DR  ROBERT  PATERSON,  LEITH. 

In  the  obituary  list  for  last  month  there  has  to  be  recorded  the 
name  of  Robert  Paterson,  M.D.,  F.R.C.P.,  and  L.B.C.S.  Ed. 
Dr  Paterson  was  born  in  Leith  in  1814,  and  died  there.  May  15th, 
1889,  being  thus  in  his  75th  year.  His  death  requires  something 
more  than  a  mere  passing  notice  in  these  pages,  his  position,  both 
as  a  citizen  and  a  medical  practitioner,  being  of  no  ordinary  character. 
Dr  Paterson  obtained  the  license  of  the  Royal  College  of  Surgeons 
of  Edinburgh  in  1835,  and  the  degree  of  M.D.  in  the  University 
there  in  1836,  and  shortly  afterwards  commenced  practice  in  Leith, 
where  he  remained,  a  busy  and  accomplished  physician,  up  to  the 
time  of  relinquishing  tlie  more  active  duties  of  his  calling  some 
years  ago.  During  his  early  life,  while  in  attendance  on  the 
medical  classes,  he  was  a  distinguished  student,  carrying  off  the 
gold  medal  in  botany,  of  which  he  was  particularly  fond,  as  he  also 
was  of  natural  history.  He  was  likewise  somewhat  of  an  authority 
in  archaeological  matters,  as  certain  of  his  writings  on  this  subject 
in  connexion  with  lona  well  exhibit.  During  his  student  career  he 
was  apprentice  to  Dr  Latta,  and  on  the  occurrence  of  the  great 
outbreak  of  cholera  towards  the  year  1832,  was  one  of  those  who 
saw  much  of  the  interesting  experiments  in  the  use  of  Steven's 
solution,  then  introduced  as  a  means  of  treatment  in  that  disease. 
Previous  to  entering  upon  practice,  he  spent  a  year  in  the  great 
medical  schools  of  Paris,  which  were  at  that  time  in  high  repute ; 
and  in  1845  he  was  elected  a  Fellow  of  the  Royal  College  of 
Physicians  of  Edinburgh,  where  in  later  years  he  became  Presi- 
.1  dent, — a  position  he  held  with  much  acceptance,  and  in  which  he 

I  rendered  considerable  service  to  the  College.     Dr  Paterson  married 

a  daughter  of  Mr  Farnie,  shipbuilder  in  Burntisland,  by  whom  he 
had  thirteen  children,  seven  sons  and  six  daughters,  of  whom  three 


1160  OBITUARY.  [JUNE 

sons  and  four  daughters  still  survive.  Mrs  Paterson  died  about 
eighteen  months  ago.  Besides  many  investigations  and  literary 
contributions  in  subjects  outside  the  sphere  of  Medicine  and  Surgery, 
he  devoted  himself  with  distinguished  success  to  several  special 
departments  in  his  own  profession,  more  particularly  to  medical 
jurisprudence  and  to  midwifery,  in  both  of  which  he  was  for  long 
an  Examiner.  He  was,  from  his  early  student  days  up  to  the  time 
of  Professor  Simpson's  death,  one  of  the  most  intimate  friends 
of  that  famous  physician,  while  his  acquaintance  and  intimacy 
with  the  distinguished  Professor  Syme  were  of  such  a  nature 
as  not  only  led  Dr  Paterson  to  choose  as  the  subject  of  the 
Harveian  oration  on  the  year  in  which  this  devolved  upon  him, 
some  memoirs  of  his  friend,  but  constituted  the  ground  upon 
which  he  was  requested  to  publish  his  remarks  on  this  occasion  in 
the  extended  form  which  they  assumed  in  the  volume  appearing 
under  his  hand  in  1874,  namely,  The  Memorials  of  Professor  Syme, 
a  work  which  was  highly  commended  at  the  time,  while  it  is  now 
of  much  value  as  the  only  existing  record  of  the  life  of  that 
illustrious  surgeon.  About  fifteen  years  ago  Dr  Paterson  built  a 
handsome  villa  at  St  Catherines,  on  the  beautiful  shores  of  Loch 
Fyne,  and  immediately  opposite  Inveraray.  Here  it  was  his  delight 
to  sojourn  with  his  family  and  friends  during  the  summer  and 
autumn  months,  and  many  fond  recollections  of  his  kindly  and 
social  qualities  will  no  doubt  ever  be  present  with  those  com- 
panions who  enjoyed  his  hospitality  at  "The  Pines."  Dr  Paterson 
was  fond  of  field  sports,  and  was  an  excellent  shot,  while  his  powers  of 
endurance  were  remarkable.  It  was  at  "  The  Pines  "  that  his  first 
attack  of  the  malady  which  resulted  in  his  death  occurred.  This 
was  in  1883,  subsequently  to  which  time  several  other  paralytic 
seizures  had  taken  place,  the  last  about  a  fortnight  ago,  and 
from  which  he  never  rallied.  Although  Dr  Paterson  continued 
to  practise  in  Leith,  he  had  been  on  several  occasions  pressed 
to  remove  to  Edinburgh,  and  carry  on  his  profession  there. 
This,  however,  he  always  declined,  the  last  time  of  his  doing  so 
being  on  the  departure  of  Dr  Matthews  Duncan  for  London.  His 
practice  was  an  extensive  one,  and  he  enjoyed  the  esteem  and 
confidence  of  all  his  patients.  His  funeral  on  Saturday,  May  18th, 
was  largely  attended.  In  addition  to  his  many  personal  friends, 
both  the  President  and  representatives  of  his  own  and  many  of  the 
sister  College  were  present,  while  the  number  of  persons  congre- 
gated on  the  streets  through  which  the  cortege  passed  showed  that 
his  death  had  produced  no  inconsiderable  sensation  and  regret  in  his 
native  town.  

DR  ALEXANDER  HARVEY. 

Dr  Alexander  Harvey,  Emeritus-Professor  of  Materia  Medica 
in  the  University  of  Aberdeen,  was  one  of  the  few  survivors  of  a 
type  of  men  that  has  done  excellent  work,  and  has  filled  an 
honourable  position  in  the  progress  of  the  medical  profession,  but 


1889.]  DR   ALEXANDER   HARVEY.  1161 

that  is  passing  away  from  among  us.  The  wide  views  that  were 
possible  to  the  abler  men  of  the  past  generation  are  in  danger  of 
being  crushed  aside  by  the  specialization  and  depth  of  study  now 
necessary  to  attain  a  front  rank  in  any  department  of  the  pro- 
fession. 

Professor  Harvey  was  characterized  by  wide  tastes  and  sym- 
pathies in  the  progress  of  Medicine  and  the  allied  sciences,  warm 
interest  in  the  prosperity  of  the  University  of  Aberdeen  and  of 
medical  education,  and  great  kindliness  of  disposition,  experienced 
at  all  times  by  his  students,  and  securing  to  him  their  esteem  both 
as  a  teacher  and  as  a  friend.  By  many  of  his  former  students  his 
death  has  been  felt  as  a  personal  loss. 

He  was  born  on  20th  April  1811,  at  Broomhill,  in  Aberdeen- 
shire, being  the  second  son  of  Eobert  Harvey,  M.D.,  of  Broomhill 
and  Braco  in  Aberdeenshire,  and  of  Mornefendue  in  Grenada, 
W.I.,  in  which  last  property  he  succeeded  his  grandfather,  Dr 
Alexander  Gordon,  who  wrote  on  puerperal  fever. 

The  subject  of  this  notice  was  educated  in  Aberdeen  in  the 
Grammar  School,  and  then  in  Marischal  College  and  University, 
in  which  he  graduated  A.M.  in  due  course.  He  then  entered  upon 
the  study  of  Medicine,  attending  the  medical  schools  of  Dublin, 
Paris,  London,  and  Edinburgh,  in  which  last  city  he  took  L.RC.S. 
in  1832,  and  M.D.  in  1835. 

In  1831,  by  the  death  of  his  brother,  he  succeeded  to  the  family 
estates,  but  the  emancipation  of  the  slaves  in  the  West  Indies  so 
greatly  reduced  the  value  of  the  property  in  Grenada  that  he  sold 
it  and  the  others  also,  and  devoted  himself  wholly  to  the  practice 
of  his  profession  in  Aberdeen. 

Previous  to  1860  there  was  no  well-equipped  medical  school  in 
Aberdeen,  there  being  two  rival  universities,  viz.,  King's  College 
and  University  in  Old  Aberdeen,  and  Marischal  College  and 
University  in  Aberdeen.  Each  endeavoured  to  form  a  medical 
school,  and  as  there  were  very  few  chairs  of  Medicine  in  either, 
the  substitute  was  resorted  to  of  appointing  lecturers  in  such 
departments  of  study  as  were  not  otherwise  provided  for.  The 
medical  schools  were  in  part  rivals,  and  in  part  supplemented 
each  other,  the  lecturers  frequently  holding  appointments  in  both. 
Dr  Harvey  was  for  several  years  Lecturer  on  Physiology  in 
Marischal  College,  and  also  was  Lecturer  on  Practice  of  Medicine 
in  King's  College. 

Eesigning  these  posts  he  removed  in  1852  to  Southampton, 
where  he  remained  in  medical  practice  till  1858,  in  which  year  he 
returned  to  Scotland  and  settled  in  Cupar-Fife. 

The  Executive  Commission  appointed  in  1858  to  carry  through 
reforms  in  the  Scottish  Universities  effected  the  union  of  the  two 
Universities  of  Aberdeen  in  1860,  and  placed  the  medical  equip- 
ment of  the  University  on  a  footing  more  suited  to  the  require- 
ments of  the  profession  than  had  previously  been  possible.     Several 

EDINBURGH  MED.   JOURN.,   VOL.   XXXIV. — NO.   XII.  7  H 


1162  OBITUARY.  [JUNE 

new  chairs  were  instituted,  among  which  was  Materia  Medica. 
Dr  Harvey  was  appointed  to  this  new  chair ;  and  he  proved  himself 
worthy  of  the  position  by  the  assiduity  with  which  he  discharged 
the  duties  that  specially  fell  on  him  as  its  first  occupant,  and  by 
his  influence  on  those  whom  he  taught. 

His  honourable  and  upright  character  won  him  universal  respect 
and  esteem  in  the  medical  profession  where  he  laboured,  as  mani- 
fested, among  other  evidences,  by  his  appointment  in  1874  to  the 
office  of  President  of  the  North  of  Scotland  Medical  Society,  and 
in  1877  to  the  same  office  in  the  Harveian  Society  of  Edinburgh. 
He  was  for  several  years  Physician,  and  afterwards  Consulting 
Physician,  to  the  Aberdeen  Royal  Infirmary,  Dispensary,  and  Home 
for  Incurables. 

While  a  teacher  in  the  University,  he  made  himself  familiar 
with  the  disputed  questions  of  Medical  Education,  and  aided,  both 
by  word  and  pen,  in  their  due  consideration.  His  views  were  well 
put  forward  in  a  series  of  letters  addressed  to  the  late  Sir  James 
Clarke,  which  deserve  careful  perusal. 

His  health  began  to  give  way  after  1870,  and  in  1878  he  felt 
himself  obliged  to  resign  the  professorship,  and  removed  to  the 
less  trying  climate  of  London,  where,  though  suffering  from 
impaired  health,  he  continued  to  manifest  a  strong  interest  in  his 
former  pursuits  till  the  close  of  his  life.  About  ten  days  before 
his  death  he  was  attacked  by  bronchitis,  which  seemed  to  be  pass- 
ing off;  but  on  Tuesday,  23rd  April,  a  low  form  of  pneumonia  set 
in,  and  early  on  the  morning  of  Thursday,  25th  April,  he  passed 
quietly  away. 

He  frequently  contributed  to  the  medical  journals,  and  also 
published  some  longer  works  in  his  favourite  studies.  Among  the 
more  important  of  these  were — "A  Eemarkable  Effect  of  Cross- 
breeding" (1851);  "Trees  and  their  Nature,  or  the  Bud  and  its 
Attributes"  (1856);  "Man's  Place  and  Bread  Unique  in  Nature" 
(1865) ;  "  First  Lines  of  Therapeutics,  based  on  the  Modes  of 
Healing  as  occurring  spontaneously  in  Disease,  and  on  the  Modes 
of  Dying  as  resulting  naturally  from  Disease"  (1879);  and  "On 
the  Foetus  in  Utero  as  Inoculating  the  Maternal  with  the  pecu- 
liarities of  the  Paternal  Organism"  (1886). 

Dr  Harvey  in  1840  married  Anne  Farquharson  Smith,  daughter 
of  the  late  Alexander  Smith  of  Glenmillan,  who  survives  him. 
His  family  numbered  Dr  Eobert  Harvey,  Brigade-Surgeon  in  the 
Indian  Army ;  Mr  Alexander  S.  Harvey,  formerly  in  the  Consular 
Service  in  China,  and  now  a  barrister  in  London ;  the  Rev.  William 
Harvey,  who  died  in  1872  ;  and  three  daughters,  of  whom  the 
eldest  married  Surgeon-Major  L.  D.  Spencer,  and  the  second  Mr 
R.  H.  Burnett. 


DAVID  WYLIE,  L.K.C.S.Ed.,  OF  ERROL. 
For  nearly  the  whole  of  this  century  Wylies  of  Errol  have  been 
the  chief  practitioners  in  the  fertile  Carse  of  Gowrie ;  certainly  for  a 


1889.]  DAVID   WYLIE,   OF   ERROL.  1163 

time  there  was  no  one  else  between  Perth  and  Dundee  for  the  22 
miles  of  cornfields  and  orchards  which,  bounded  by  the  Tay  and  the 
Sidlaw  Hills,  gradually  broaden  out  as  the  Tay  nears  the  sea. 
David  Wylie's  father  was  a  very  remarkable  man  ;  a  splendid  horse- 
man and  sportsman,  he  managed  to  find  time  to  do  his  medical  and 
surgical  work,  and  to  have  about  as  much  country  pastime  as  the 
idlest  laird  of  them  all.  Riding  or  driving  very  fast  horses,  he  got 
over  the  good  roads  rapidly,  and  seemed  omnipresent  at  sickbed  or 
cover- shoot.  David  was  of  a  slower  and  quieter  type,  but  worked 
for  nearly  thirty  years  with  much  acceptance,  till  failing  health, 
rheumatism,  and  chest-mischief,  gradually  brought  the  end.  He 
was  much  liked,  and  will  be  missed  by  many. 


DR  W.  M'CULLOCH  WATSON  OF  MONTROSE. 

William  M'Culloch  Watson  died  at  his  residence,  Montrose, 
after  a  lingering  and  painful  illness,  at  the  age  of  50.  In  his 
student  days  in  Edinburgh,  fully  thirty  years  ago,  he  was  a  man  of 
mark,  a  great  favourite  with  his  fellow-students,  a  keen  worker  in 
Syme's  Wards,  where  he  served  for  several  years  as  dresser  and 
clerk,  and  a  devoted  member,  afterwards  a  president,  of  the  Royal 
Medical  Society.  He  was  a  thorough  gentleman  in  the  highest 
sense  of  the  word,  courteous  and  loyal,  with  a  fund  of  quaint 
humour  and  anecdote,  rendered  doubly  valuable  by  a  solemn 
countenance,  which,  at  will,  he  could  render  absolutely  expression- 
less. He  has  practised  for  many  years  at  Montrose,  respected  and 
loved  by  all  who  knew  him,  though  of  late  years  the  state  of  his 
health  has  interfered  much  with  active  practice.  He  was  an  M.D. 
of  the  University  of  Edinburgh,  and  an  L.R.C.S.  Ed. 

His  younger  brother,  the  late  lamented  Morrison  Watson, 
Professor  of  Anatomy  at  Manchester,  died  some  years  ago  in  the 
very  prime  of  life  and  work. 


DR  F.  A.  TURTON,  Surgeon-Major. 

Surgeon-Major  F.  A.  Turton  died  in  Birmingham,  April  30  th, 
1889,  aged  52  years,  at  the  residence  of  Capt.  Stoneman,  Army 
Service  Corps,  38  Duchess  Road,  Edgebaston,  and  was  interred. 
May  3rd,  in  Witton  Cemetery  in  the  suburbs. 

Dr  F.  A.  Turton  was  born  in  1837  in  the  West  Indies,  and  went 
through  his  medical  education  in  Edinburgh,  where  he  obtained  the 
diplomas  of  L.R.C.S.  and  L.M.  Ed.  in  1858. 

Subsequently,  in  1867,  he  received  the  diplomas  at  Edinburgh 
of  L.R.C.P.  and  F.R.C.S.E.,  and  afterwards  the  degree  of 
M.D.  of  Heidelberg.  He  entered  the  army  in  1858  as  assistant 
surgeon,  was  promoted  to  be  surgeon  in  1873,  surgeon-major  in 
1874,  and  had  retired  from  active  service  not  many  weeks  before 
his  decease. 

He  had  served  in  the  11th  and  23rd  regiments,  and  went  through 
the  Ashanti  war,  having  been  present  at  the  actions  of  Amoaful 


1164 


OBITUARY. — PUBLICATIONS   RECEIVED. 


[JUNE  1889. 


Ordahsu,  Cooraassi,  etc.,  for  which  he  was  mentioned  in  despatches, 
and  received  the  medal  and  clasp.  He  had  also  been  stationed  for 
some  years  in  India.  Latterly  his  health  had  become  impaired  by 
the  accession  of  chronic  Bright's  disease  of  the  kidneys  induced  by 
tropical  service,  and  the  fiital  issue  was  hastened  by  the  advent  of 
affection  of  the  heart. 


PUBLICATIONS  KECEIVED. 


J.  W.  Anderson,  M.D.,— The  Essentials  of 
Physical  Diagnosis  of  the  Chest  and 
Abdomen.  James  Maclehose  &  Sons, 
Glasg.,  1889. 

A.  H.  F.  Barbour,  M.D.,  etc.,— The 
Anatomy  of  Labour  as  studied  in  Frozen 
Sections,  and  its  bearing  on  Clinical  Work. 
W.  &  A.  K.  Johnston,  Edinb.,  1889. 

Dr  Barry, — Report  on  an  Epidemic  of  Small- 
pox at  Sheffield  during  1887-88. 

Edward  Berdoe,— The  Futility  of  Experi- 
ments with  Drugs  on  Animals.  Society 
for  Protection  of  Animals  from  Vivisection. 
Lond.,  1889, 

A.  E.  Bridqer,M.D., — Man  and  HisMaladies, 
John  Hogg,  Lond.,  1889. 

S.  S.  Burt,  M.D.,— Exploration  of  the  Chest 
in  Health  and  Disease.  D.  Appleton  &  Co., 
New  York,  1889. 

F.  M.  Cairo,  M.B.,  and  C.  W.  Cathcart, 
M.B., — A  Surgical  Handbook  for  the  Use 
of  Students,  Practitioners,  House-Sur- 
geons,  and  Dressers.  Chas.  Griffin  & 
Co.,  Lond.,  1889. 

H.  DoBELL,  M.D., — On  Bacillary  Con- 
sumption. Smith,  Elder,  &  Co.,  Lond., 
1889. 

F.  GusTAV  Ernst, — A  Guide  to  the  Selec- 
tion and  Adaptation  of  Orthopaedic  Appar- 
atus.    Sprague  &  Co.,  Lond.,  1889. 

Dr  E.  Henoch, — Lectures  on  Children's 
Diseases.  New  Sydenham  Society,  Lond., 
1889. 

Jonathan  Hutchinson,  Jun.,  F.R.O.S., — 
Aids  to  Ophthalmic  Medicine  &  Surgery, 
Bailliere,  Tindall,  &  Cox.,  Lond.,  1889. 

Alex.  James,  M.D., — Pulmonary  Phthisis. 
Young  J.  Pentland,  Edin.,  1888. 

Kemp  &  Co.'s  Prescriber's  Pharmacopoeia  of 
New  Drugs.  Kemp  &  Co.,  Bombay, 
1889. 

E.  N.  Khory,  M.D., — The  Bombay  Materia 
Medica  and  their  Therapeutics.  Bombay, 
1887. 

A.  Kinsey-Morgan,  M.R.C.S., — Bourne- 
mouth as  a  Health  Resort.  Simpkin, 
Marshall,  &  Co.,  Lond.  1889. 

E.  Klein,  M.D., — The  Bacteria  in  Asiatic 
Cholera.     Macmillan  &  Co.,  Lond.,  1889. 

W.  P.  Letchworth, — The  Insane  in  Foreign 
Countries.  G.  P.  Putnam's  Sons,  New 
York  and  Lond.,  1889. 

R.  A.  D.  LiTHOow,  LL.D.,  L.R.C.S.  Ed,, 
etc.,  etc.,— Heredity.  Baillifere,  Tindall, 
&  Cox,  Lond.,  1889. 

Agnes  C.  Maitland, — What  shall  we  have 
for  Breakfast?    John  Hogg,  Lond.,  1889. 

J.  F.  Malgaigne. — Manuel  de  M^decine 
Operatoire.    Bailliere  et  Cie.    Paris,  1889. 

Ahoel  Money,  M.D., — Student's  Text-book 


of  the  Practice  of  Medicine.    H.  K.  Lewisi 

Lond.,  1889. 
Periodicals,  etc.,  in  the  Librarjr  of  the  New 

York    Academy    of    Medicme,    Part    I. 

Boston,  1889. 
W.   S.   Playpair,  M.D.,   LL.D.,  etc.,— A 

Treatise  on  the  Science  and  Practice  of 

Midwifery.      2   vols.      Smith,    Elder,    & 

Co.,  Lond.,  1889. 
A.  L.  Ranney,  A.M.,  M.D., — Lectures  on 

Nervous  Diseases.     F.  A.  Davis,  Phila- 
delphia and  London,  1889. 
R.  R.   Rentoul,   M.D., — The  Causes  and 

Treatment  of  Abortion.     Young  J.  Pent- 
land,  Edin.,  1889. 
A.  W.  M.  RoBSON,  F.R.C.S.,— A  Guide  to 

the  Instruments  and  Appliances  required 

in  various  Operations.    J.  &  A.  Churchill, 

Lond.,  1889.      • 
Bernard   Roth,   F.R.C.S., — Treatment   of 

Lateral  Curvature  of  the  Spine.     H.  K. 

Lewis,  Lond.,  1889. 
C.  E.  Armand  Semple, — Essentials  of  Patho- 
logy and  Morbid  Anatomy.     Henry  Ren- 

shaw,  London, 1889. 
R.  M.  Smith,  A.M.,  M.D.,— The  Physiology 

of  the  Domestic  Animals.     F.  A.  Davis, 

Philadelphia  and  London,  1889. 
Noble  Smith,  F.R.C.S.E., — Curvatures  of 

the  Spine.     Smith,  Elder,  &  Co.,  Lond., 

1889. 
J.  K.  Spender,  M.D., — Early  Symptoms  and 

Early  Treatment  of  Osteo-Arthritis.     H. 

K.  Lewis,  Lond.,  1889. 
John  Strahan,  M.D., — The  Diagnosis  and 

Treatment  of  Extra-uterine    Pregnancy. 

P.  Blakiston,  Son,  &  Co.,  Philadelphia, 

1889. 
Transactions  of   American    Association    of 

Obstetricians  and  Gynecologists,  Vol.  I. 

Philadelphia,  1888. 
Transactions    of    the    Clinical    Society    of 

London,  Vol.  XXI.    Longmans,  Green,  & 

Co.,  Lond.,  1888. 
Transactions  of  the  Obstetrical   Society  of 

London,    Part   I.,    Vol.    XXXI.    Lond., 

1889. 
Francis  Vacher, — Defects    in    Plumbing 

and  Drainage   Work.      John   Heywood, 

Manchester,  1889. 
Samuel  Wilks,  M.D.,  F.R.S., — Lectures  on 

Pathological  Anatomy.    Longmans,  Green, 

&  Co..  Lond.,  1889. 
H.  P.  Wright,  M.A.,— Leprosy  an  Imperial 

Danger.     J.  &  A.  Churchill,  Lond.,  1889. 
Year-book   of  the    Scientific   and    Learned 

Societies   of   Great    Britain   and    Ireland. 

Charles  Griffin  &  Co.,  Lond.,  1889. 
17th  Annual  Report  of  the  Local  Government 

Board,  1887-88;  with  Supplement. 


INDEX. 


Abdominal  section,  an  analysis  of  one  hun- 
dred and  thirty  cases  of,  by  J.  H.  Groom, 
M.D.,  1010. 
Abdominal  surgery,  notes  of  a  year's  work 
in,  by  Rutherford  Morison,  M.D.,  40,  146. 
Abdominal  tumours,  diagnosis  of,  375. 
Abortion,    relationship    between    neuralgia 

and,  by  A.  D.  Leith  Napier,  M.D.,  707. 
Abscess,  and  microbism,  860  ;  retropharyn- 
geal, 1065. 
Aconitine,  poisoning  by,  574. 
Acromegaly,  861. 
Actinomycosis,  384,  955. 
Adams,  Calvin   Thayer,  M.D.,  elongatio 

colli  supra  vaginalis,  144. 
Address,  valedictory,  to  Edinburgh  Obstet- 
rical Society,  by  J.  H.  Groom,  M.  D.,  47  ; 
introductory  to,  by  G.  E.  Underbill,  M.B., 
512. 
Address  on  scientific  medicine  and  bacteri- 
ology in   reference  to  'the  experimental 
method,  by  Prof.  Mariano  Semmola,  336, 
439. 
Address,  inaugural,  to  the  Royal  Medical 

Society,  by  Prof.  W.  S.  Greenfield,  624. 
./Esculap,  391. 

Affleck,  J.  0.,  M.D.,  the  clinical  value  of 

temperature  observations  in  some  acute 

and  chronic  diseases,  7 ;    case  of  reflex 

spastic  paraplegia  under  the  care  of,  1118. 

Albuminuria,  febiile,  in  childliood,  673. 

Allingham,  Wm.,  F.R.C.S.,  diseases  of  the 

rectum,  rev.,  550. 
Alopecia  areata,  848. 

Amblyopia  in  nitro-benzol  poisoning,  964. 
Amylene  hydrate,  758. 
Anaesthetics,  valuable  lesson  for  those  who 

use,  770. 
Anatomy  and  physiology,  journal  of,  vol. 

xxii.,  rev.,  60. 
Anderson,  J.  Walker,  M.D.,  the  essentials 
of   physical  diagnosis  of  the  chest  and 
abdomen,  rev.,  1125. 
Anderson,   Prof.    T.    M'Call,   dermatitis 

herpetiformis,  881. 
Aneurism,  treatment  of,  669 ;  spontaneous 

cure  of  abdominal,  954. 
Annales    medico  -  chirurgicales,    December 

1887,  rev.,  58. 
Annals  of  surgery,  rev.,  159,  466. 
Annandale,  Prof.  Thomas,  case  of  acute 
intussusception  in  a  child  three  years  of 
age  successfully  relieved   by  abdominal 
section,  777. 
Anthelmintic,  a  new,  1062. 
Anthrarobin,  175,  561,  960. 
Antifebrin    as    an    anti-epileptic,    276 ;    in 

sciatica,  953  ;  as  a  poison,  957. 
Antipyrin     in       epidemic       cerebro-spinal 
meningitis,  73  ;  haemostatic  action  of,  75  ; 
tabloids  of  compressed,  183 ;  in  suppress- 


ing the  milk  secretion,  478  ;  coffee  as  a 
vehicle  for,  559  ;  in  the  treatment  of 
malarial  fevers,  559  ;  in  rheumatism  and 
neuralgia,  563;  in  acute  articular  rheu- 
matism, 757;  in  the  nasal  passages,  758; 
in  sciatica,  1062  ;  contraindications  for 
the  use  of,  during  the  menstrual  period, 
1062  ;  the  physiological  efl'ects  of,  1149. 

Archibald,  Dr,  St  Andrews,  obituary,  970 

Army  Medical  Department,  363;  school,  365. 

Arnott,  Surgeon-Major,  M.D.,  a  successful 
case  of  Caesarean  section,  140. 

Arragon,  Catherine  of,  notes  on  the  obstetric 
history  of,  by  Andrew  S.  Gurrie,  M.D., 
294. 

Ascites,  calomel  and  digitalis  in,  563. 

Asexualization  as  a  penalty  for  crime,  574. 

Association,  British  Medical,  at  Glasgow,  284. 

Association  of  American  Physicians,  trans- 
actions of,  rev.,  475. 

Association,  the  New  York  State  Medical, 
transactions  of,  vol.  iii.,  rev.,  474. 

B 

Baker,  H.  B.,  M.  D.,  malaria,  and  the  causa- 
tion of  periodic  fever,  rev.,  931. 

Balfour,  J.  Craig,  L.K.G.P  and  S.Ed., 
case  of  inguinal  hernia  in  a  female  child 
with  curious  complications,  905. 

Ballantyne,  J.  W.,  M.D.,  the  labia  minora 
and  hymen,  425. 

Barbour,  A.  H.  F.,  M.D.,  the  third  stage 
of  labour,  97  ;  early  contributions  of  ana- 
tomy to  obstetrics,  227,  328,  450  ;  note  on 
Saexinger's  and  Winter's  sections,  1091. 

Bartholow,  Robert,  M,  A.,  M.D.,  a 
practical  treatise  on  materia  medica  and 
therapeutics,  rev.,  58. 

Basedow's  disease,  954. 

Beef,  fluid,  and  chicken  extract,  183. 

Bell,  Dr  George  William,  obituary,  772. 

Bennett,  Prof.  E.  H.,  M.D.,  the  sectional 
anatomy  of  congenital  caecal  hernia,  rev., 
469. 

Berry,  George  A.,  M.D.,  periscope  of  oph- 
thalmology, 961. 

Birmingham  Medical  Review,  771. 

Bite,  room  to,  95. 

Boleyn,  Anne,  notes  on  obstetric  history  of, 
by  Andrew  S.  Gurrie,  M.D. ,  294. 

BoNTHRON,  Dr,  of  West  Linton,  obituary, 
972. 

Boric  acid  in  intermittent  fever,  953. 

Bottentujt,  Dr,  the  waters  of  Plombieres 
(Vosges),  rev.,  348. 

"  Bourboule,  La,"  mineral  water,  1070. 

Brain,  tumours  of  the,  in  cliildren,  1066. 

Braithwaite,  J.,  M.D.,  retrospect  of  medi- 
cine, rev.,  744. 

Bramwell,  J.  P.,  M.D.,  an  abstract  of  24 
cases  of  serous  pleural  effusion  treated  by 
pneumatic  aspiration,  909. 


1166 


INDEX. 


[1888- 


Breast,  carcinoma  of  the,  967. 

Bkewis,  N.  T.,  M.B.,  twelve  cases  of  lapar- 
otomy for  disease  of  the  uterine  append- 
ages, 117. 

Bridger,  a.  E.,  B.A.,  M.D.,  the  demon  of 
dyspepsia,  rev.,  642. 

Bristowe,  J.  S.,  M.D.,  clinical  lectures  and 
essays  on  diseases  of  the  nervous  system, 
rev.,  931. 

Brocq,  Dr,  de  la  dermatite  herp^tiform  de 
Duhring,  rev.,  928. 

Bkodhurst,  Bernard  E.,  F.R.C.S.,on  cur- 
vatures and  diseases  of  the  spine,  re«.,742. 

Brooklyn  Medical  Journal,  rev.,  939. 

Brown,  W.  Symington,  M.D.,  a  clinical 
handbook  on  the  diseases  of  women,  rev., 
741. 

Bruck,  Ludwio,  guide  to  the  health  resorts 
in  Australia,  Tasmania,  and  New  Zealand, 
rev.,  256. 

Bryant,  Thomas,  F.R.  C.  S.,  Hunterian  lec- 
tures, rev.,  841. 

Bull,  Edwin  G.,  M.B.,  occasional  periscope 
of  surgery,  858. 

BuLLEN,  M.  W.,  and  A.  H.,  a  dialogue 
against  the  fever  pestilence,  rev.,  246. 

Burns,  cocaine  and  lanolin  in,  75. 

Butyl-chloral  in  trigeminal  neuralgia,  1061. 

Buxton,  D.  W.,  M.D.,  anaesthetics,  their 
uses  and  administration,  rev.,  471. 

Byford,  Prof.  W.  H.,  the  practice  of  medi- 
cine and  surgery  applied  to  the  diseases 
and  accidents  incident  to  women,  rev.,  544. 

0 
Cadell,   Francis,  F.R.C.S.,  periscope  of 

syphilology,  89,  482,  575,  854. 
Caesarean  section,   a  successful  case  of,  by 

Surgeon-Major  Arnott,  140. 
Caffein,  double  salts  of,  in  diseases  of  the 

lungs,  279. 
Caikd,  John,  D.  D.  ,  mind  and  matter,  rev., 

651. 
Campbell,  C.  M.  ,  M.D.,  the  skin  diseases 

of  infancy  and  early  life,  rev.,  1036. 
Canary  Islands,  personal    experiences  of  a 

winter  in  the,  by  H.  C.  Taylor,  M.D.,  607. 
Carcinoma  of  the  face,  final  issue  in,  378 ; 

of  the  stomach,  condurango  in,   671 ;  of 

the  larynx,  859,  861  ;  of  the  breast,  967. 
Carlsbad  mineral  water,  391. 
Carter,  Alfred  H.,  M.D.,  elements  of  prac- 
tical medicine,  rev.,  642. 
Cascara  sagrada  in  rheumatism,  559. 
Cathcart,   G.  W.  ,  M.B.,  artificial  limbs, 

819. 
Cerebellum    and    pons    varolii,  a     case    of 

tumours  of  the,  673. 
Cervix,  the  diagnosis  of  beginning  carcinoma 

of  the,  87. 
Chapman,  J.  Milne,   M.D.,   periscope  of 

gynaecology  and  midwifery,  85,  381,  564, 

850. 
Charts,  clinical,  and  outline  figures,  679. 
Cheyne-Stokes  respiration,  an  examination 

of  the  phenomena  in,  by  George  A.  Gibson, 

585,  681,  801,  887,  1020,  1105. 
Children,  occasional  periscope  of  diseases  of, 

by  C.  E.  Underbill,  M.B.,  281,  672  1065. 
Chloral,  the  treatment  of  night  sweats  by  the 

external  use  of,  1061. 


Cholera    infantum    and  the  weather,  281  ; 

etiology  of  chicken,  860 ;  a  new  remedy 

for,  1063. 
Chorea,  treatment  of,  by  physostigmine,  277. 
Christie,  D.,  L.R.C.P.  and  S.Ed.,  report 

of  medical  missionary  work  in  Manchuria, 

rev.,  258. 
Cleland,  Prof.  J.,  memoirs  and  memoranda 

in  anatomy,  rev.,  935. 
Clinical  reports  of  cases,  829,  925,  1031. 
Coats,  Joseph,  M.D.,  on  the  pathology  of 

phthisis  pulmonalis,  rev.,  538. 
Cocaine  in  the  treatment  of  burns,  759. 
Codeine  in  diabetes  mellitus,  757. 
Colli  supra  vaginalis,  elongatio,  by  Calvin 

Thayer  Adams,  144. 
Collier,  W.,  M.D.,  hydrophobia,  a  review 

of  Pasteur's  treatment,  rev.,  650. 
Collinsonia  Canadensis  liquidum,  extr.,  182. 
Colon,  case  of  gangrene  of  transverse,  in  an 

umbilical  hernia,  by  J.  M.  Cotterill,  M.B., 

602. 
Combe,  Deputy  Surgeon-General,  obituary, 

969. 
Condurango  in  carcinoma  of  the  stomach, 

671. 
Congrfes  Fran^ais  de  Chirurgie,  3°  session, 

rev.,  740. 
Congres  international   de  th^rapeutique  et 

de  matifere  m^dicale,  1157. 
Congres  international  d'otologie  et  de  laryn- 

gologie,  1158. 
Congress,  intercolonial  medi*cal,  582. 
Congress  of  American   physicians  and  sur- 
geons, 91. 
Contagious  diseases  acts,  the  abolition  of  the, 

in  Italy,  89. 
Corn  cure,  an  infallible,  680. 
Cornea,  v.  Hippel's  method  of  transplanting, 

963. 
Corns  of  sole,  Unna's  treatment  of,  567. 
Correspondence,  391,  080,  774,  973. 
Coryza,  bacteria  of  acute  and  chronic,  481. 
Cotterill,  J.  M.,M.B.,  case  of  gangrene  of 

the  transverse  colon  in  an  umbilical  hernia, 

602. 
Craig,  Wm.,  M.D.,  monthly  report  on  the 

progress  of  therapeutics,  73,  276,  476,  558, 

669,  757,  951,  1061,  1149. 
Craniotomy  versus  premature  labour,  turn- 
ing, and  perforation,  382. 
Creosote  in  phthisis,  ,562. 
Crocker,  H.  li.,  M.D.,  diseases  of  the  skin, 

rev.,  250. 
Ckoft,  John,  F.R.C.S.,  internal   urethro- 
tomy, 1-ev.,  255. 
Croom,    J.  Halliday,    M.D.,   valedictory 

address    to    the     Edinburgh    Obstetrical 

Society,  47  ;  an  analysis  of  130  cases  of 

abdominal  section,  1010. 
Cures,  strange,  770. 
CuRKiE,  Andrew  S.,   M.D.,  notes  on  the 

obstetric  histories  of  Catherine  of  Arragon 

and  Anne  Boleyn,  294. 
Cutaneous  and  genito-urinary  diseases,  jour- 
nal of,  rev.,  930. 
Cystotomy,  suprapubic,  84. 

D 
Dale,  Ridley,  M.D.,  epitome  of  surgery, 
rev.,  1037. 


188'J.] 


INDEX. 


1167 


Davies,  George,  physiological  diagrams  for 

use  in  schools,  rev.,  1129. 
Dermatitis  herpetiformis,  by  Prof.  T.  M'Call 

Anderson,  881. 
Dermatitis  tuberosa  of  iodic  origin,  849, 
Dermatological  don'ts,  850. 
Dermatologie  et  de  syphiligraphie,  annales 

de,  rev.,  930. 
Dermatology,  British  Journal  of,  rev.,  744. 
Dermatology,  occasional  periscope  of,  by  W. 

Allan  Jamieson,  M.D.,  77,  175,  378,  567; 

760,  848,  958,  1154. 
Deutsch-Medicinische-Schrift-Sucht,  486. 
Dewae,  Dr  Wm.,  of  Kirkcaldy,  obituary, 

971. 
Diabetes  mellitus,   the    relative    value    of 

opium,  morphine,  and  codeine  in,  757. 
Diary  and  visiting  list,  ABC,  rev.,  653. 
Dictionary,     an    illustrated     encyclopaedic 

medical,  rev.,  938. 
Diphtheria,  the  treatment  of,  in  children  by 

steam  medicated  with  sulphurous  acid,  by 

T.  W.  Pairman,  L.R.C.P.  and  S.  Ed. ,  724  ; 

influence  of  sewerage  and  water  pollution 

on  the  prevalence  and  severity  of,  1067. 
Disinfection  and  disinfectants,  957. 
Dispensing,  the  art  of,  rev.,  551. 
Donaldson,  S.  James,  M.D.,  contributions 

to  practical  gynaecology,  rev.,  646. 
Donders,  the  jubilee  of  Prof.,  765. 
DoRAN,     Alban,     H.    G.,     handbook    of 

gynaecological  operations,  rev.,  1038. 
Douglas,  Kenneth  M.,  M.B.,  the  osteoclast 

as  a  means  of  redressing  deformities  of 

limbs,  916. 
Duff,  George,  M.A.,  M.D.,  obituary,  773. 
Duncan,  Andrew,  M.D.,  the  prevention  of 

disease  in  tropical  and  subtropical  cam- 
paigns, rev.,  548. 
Duncan,  Mr  John,  clinical  report  of  case, 

829. 
Duodenostomy,  582. 

Dyspnoea,  cardiac,  iodide  of  potassium  in,  478. 
Dystocia  from  short  or  coiled  funis,  88. 

E 

Ebstein,  Prof.  W. ,  la  goutte  sa  nature  et 
son  traitement,  rev.,  648. 

Eczema,  treatment  of  infantile,  380. 

Eczematous  eruption,  chronic,  accidents  that 
may  happen  from  the  suppression  of  a,  959. 

Edinburgh  graduate,  honour  to  an,  485. 

Education  and  examinations,  medical,  in- 
formation regarding,  354. 

Edwards,  W.  A.,M.D.,and  J.  M.  Keating, 
M.D.,  diseases  of  the  heart  and  circulation 
in  infancy  and  adolescence,  rev.,  465. 

Elephantiasis  arabum,  note  on  a  ease  of,  by 
R.  W.  Felkin,  M.D.,  779. 

Empyema,  an  inquiry  into  the  methods  of 
cure  of,  by  J.  W.  B.  Hodsdon,  M.D.,  495. 

Endometritis,  chronic,  treatment  of,  566. 

Eneuresis  nocturna  in  boys,  375. 

Entropion,  Russian  operation  for,  961. 

Epilepsy,  picrotoxin  in,  951. 

Erysipelas,  on  the  curative  eflfect  of,  on 
various  forms  of  disease,  80. 

Erythema  nodosum,  peculiar  eye  symptoms 
in  association  with,  571. 

EsMAKCH,  Dr  F.  VON,  the  surgeon's  hand- 
book, rev.,  252. 


Everett,   Graham,  doctors   and    doctors, 

rev.,  62. 
Examination  papers  for  H.M.  Army,  Indian, 

and  Naval  medical  services,  371. 
Extremity,  amputation  of  the  upper,  in  the 

contiguity  of  the  trunk,  82. 


Fayrer,  Sir  Joseph,  chronic  tropical  diar- 
rhoea, 205 ;  the  natural  history  and  epi- 
demiology of  cholera,  rev.,  256. 

Felkin,  R.  W.,  M.D.,  note  on  a  case  of 
elephantiasis  arabum,  779  ;  foetal  malaria, 
as  illustrated  by  two  cases,  1101. 

Femoral  hernia,  notes  on  a  case  of,  accident- 
ally met  with  in  the  dead  subject,  by  W. 
Scott  Lang,  785. 

Fenwick,  E.  H.,  F.R.C.S.,  the  electric 
illumination  of  the  bladder  and  urethra, 
rev.,  255. 

Ffiufe,  Ch.,  cancer  de  la  vessie,  rev.,  640. 

Fergusson,  Wm.,  M.D.,  case  of  traumatic 
gangrene  of  penis  and  scrotum,  527. 

Ferments,  digestive,  183. 

Ferrier,  Dr,  principles  of  forensic  medicine, 
rev.,  937. 

FiNLAY,  Dr,  clinical  report  of  a  case  under 
care  of,  925. 

Fletcher's  new  patent  calendar  for  1889, 
rev.,  841. 

Flint,  Austin,  M.D.,  a  text-book  of  human 
physiology,  rev.,  1128. 

Flour,  snow-drift  cake,  183. 

Foetus,  a  case  of  parasitic,  by  B.  Langley 
Mills,  116. 

Food,  invalid,  preparations,  183. 

Fort,  Prof.  Leon  le,  manuel  de  m^decine 
op^ratoire  de  J.  F.  Malgaigne,  rev.,  59. 

Foster,  Prof.  M.,  a  text-book  of  physiology, 
rev.,  540. 

Fothergill,  Dr  John  Milne,  obituary,  184. 

FouLis,  James,  M.D.,  the  cause  of  the  head 
downward  presentation,  and  of  the  first 
cranial  position,  219,  302. 

FuRNivALL,  F.  J.,  the  anatomic  of  the  bodie 
of  man,  rev.,  247. 

G 

Gairdner,  Prof.  W.  T.,  on  the  diseases 
classified  by  the  Registrar-General  as 
tabes  mesenterica,  rer.,  538;  the  physician 
as  naturalist,  rev.,  927. 

Gall-bladder,  operations  on  the,  861. 

Gangrene,  acute  multiple  symmetrical,  762. 

Gastro-enterostomy,  582. 

Gastrotomy  for  foreign  body,  388. 

Gelsemium  sempervirens,  560. 

Geiiito-urinary  reflexes,  482. 

Gestation,  case  of  extrauterine,  by  Albert 
H.  Morison,  M.B.,  236. 

Gibson,  G.  A.,  M.D.,  remarks  on  certain 
vaso-motor  neuroses,  531 ;  an  examination 
of  the  phenomena  in  Cheyne  -  Stokes 
respiration,  585,  681,  801,  887,  1020,  1105. 

GiLLiNGHAM,  James,  artificial  limbs,  surgical 
appliances,  &tc.,rev.,  470. 

Glycerine  enemata  in  constipation,  672. 

Gordon,  C.  A.,  M.D.,  comments  on  the 
report  of  the  committee  on  M.  Pasteur's 
treatment  of  rabies  and  hydrophobia,  rev.. 
343. 


1168 


INDEX. 


[1888- 


GouLEY,  J.  W.  S.,  M.D.,  diseases  of  man, 
7'ev.i  467. 

Grafts  of  frog's  skin,  83. 

Grave's  disease,  electrical  resistance  of  the 
body  in,  384. 

Gray,  J.  Allan,  M.D.,  medicine  and 
quackery,  393;  clinical  report  of  case, 
829 ;  periscope  of  state  medicine,  572,  956. 

Greenfield,  Prof.  W.  S.,  inaugural  address 
to  the  Royal  Medical  Society,  624. 

Greville,  H.  Leicester,  F.I.C,  the 
student's  handbook  of  chemistry,  rev.,  161. 

Griffiths,  W.  Handsel,  Ph.D.,  lessons  on 
prescriptions  and  the  art  of  prescribing, 
rev.,  58. 

Gunshot  wounds,  862. 

Guy  and  Ferrier,  principles  of  forensic 
medicine,  rev.,  937. 

Guy's  Hospital  reports,  rev.,  841. 

Gynaecological  American  Society,  Trans- 
actions of,  vol.  xiii.,  rev.,  1039;  new 
method  of  examination  in,  cases,  381. 

Gynaecology  and  midwifery,  periscope  of,  by 
J.  M.  Chapman,  M.D.,  85,  381,  564,  850. 

H 

Haemoglobin,  the  quantity  of,  in  the  blood 
of  children  in  health  and  disease,  675. 

Haig,  a.,  M.D.,  the  formation  and  excretion 
of  uric  acid  considered  with  reference  to 
gout  and  allied  diseases,  rev.,  936. 

Harris,  Vincent  D.,  M.D.,  the  diseases  of 
the  chest,  rev.,   1125. 

Harrison,  Reginald,  F.R.C.S.,  lectures 
on  the  surgical  disorders  of  the  urinary 
organs,  rev.,  59. 

Hart,  D.  Beery,  M.D.,  an  improved 
method  of  managing  the  third  stage  of 
labour,  289 ;  a  contribution  to  the 
pathology,  symptoms,  and  treatment  of 
adherent  placenta,  816 ;  note  on  some 
anomalous  cases  of  separation  and  expul- 
sion of  the  placenta  before  the  birth  of  the 
child,  900  ;  the  nature  and  aim  of  investi- 
gations on  the  structural  anatomy  of  the 
female  pelvic  floor,  1095. 

Hartmann's  sanitary  wood-wool  bapkins  and 
hygienic  wood-wool  diapers,  390. 

Harveian  oration,  by  J.  Bell  Pettigrew, 
M.D.,  977, 1073. 

Harvey,  Dr  Alex.,  obituary.  1160. 

Head  downward  presentation  and  first 
cranial  position,  the  cause  of,  by  James 
Foulis,  M.D.,  2i9,  302. 

Helleboreine  as  a  local  anaesthetic,  477. 

Helleborus  viridis,  74. 

Helme,  T.  Arthur,  M.B.,  the  physiology 
of  the  third  stage  of  labour,  612. 

Hernia,  inguino-properitoneal,  577;  notes 
on  a  case  of  femoral,  accidentally  met 
with  in  the  dead  subject,  785 ;  case  of 
inguinal,  in  a  female  child,  by  J.  Craig 
Balfour,  905. 

Hewer,  Annie  M.,  antiseptics,  a  handbook 
for  nurses,  rev.,  1040. 

Higgins,  Charles,  F.R.C.S.E.,  a  manual 
of  ophthalmic  practice,  rev.,  550. 

Hodsdon,  J.  W.  B.,  M.  D.,  an  inquiry  into 
the  method  of  cure  of  empyema,  495. 

HoLDEN,  Luther,  landmarks,  surgical  and 
medical,  rev.,  347. 


Hospitals  in  connexion  with  the  medical 
schools  of  Scotland,  360. 

Hovell,  T.  Mark,  F.R.C.S.E.,  on  the 
treatment  of  cystic  goitre,  rev.,  743. 

HucHARD,  Henri,  quand  et  comment  doit- 
on  prescrire  la  digitals,  rev.,  650. 

Hummel,  A.  L.,  University  Medical  Maga- 
zine, rev.,  745. 

Husband,  H.  Aubrey,  M.B.,  the  student's 
handbook  of  the  practice  of  medicine,  rew., 
546 ;  the  student's  handbook  of  forensic 
medicine  and  public  health,  rev.,  937. 

Hyde,  James  M.,  M.D.,  a  practical  treatise 
on  diseases  of  the  skin,  rev.,  250. 

Hydrastis  canadensis,  477. 

Hydrobromates,  Fletcher's,  1069. 

Hydroxylamin,  115,5. 

Hyosciiie,  the  therapeutic  action  of,  1064;  in 
insanity,  1149. 

Hyperidrosis,  the  treatment  of,  760. 

Hysterectomy,  vaginal,  pressure  forceps 
versus  suture  and  ligature  in,  565. 


Ichthyol,  374. 

Icterus    neonatorum    and    its    relation    to 

sepsis,  674. 
Imagination  and  health,  486. 
Index  medicus,  92. 
Indian  medical  service,  366. 
Inglis,  Archibald,  M.D.,  obituary,  771. 
Injector,  ointment,  1069. 
Injector,  rectal  fluid,  1069. 
Innervation,  case  illustrating,  of  bladder, 

etc.,  479. 
Intermittent  fever,  boric  acid  in,  953. 
Intestinal  surgery,   the  statistics  of,   389; 

Dr  Senn  on,  579. 
Intussusception,   case  of  acute,  in  a  child 

three  years  of  age,  successfully  relieved 

by  abdominal   section,  by   Prof.  Thomas 

Annandale,  F.R.C.S.,  777. 
lodi,  oleum,  182. 

lodol,  the  internal  employment  of,  953. 
Ireland,  new  work  by  Dr,  285. 


Jacobson,  W.  H.  a.,  M.B.,  the  operations 
of  surgery,  rev.,  933. 

James,  Alex.,  M.D.,  physiological  and 
clinical  studies,  rev.,  154;  pulmonary 
phthisis,  its  aetiology,  pathology,  and 
treatment,  rev.,  1123. 

Jamieson,  Allan,  M.D.,  occasional  peri- 
scope of  dermatology,  77,  175,  378,  567, 
760,  848,  958,1154. 

Janitor,  the,  ahead,  679. 

Jenk's  prize,  award  of,  968. 

Johnston,  George,  M.D.,  medical  lectures 
and  essays,  rev.,  464. 

Jones,  Joseph,  M.I).,  medical  and  surgical 
memoirs,  rev.,  1126. 

K 

Karlsbad  sprudel  salt,  391. 

Keating,  J.  M.,  and  W.  A.  Edvtaeds, 
diseases  of  the  heart  and  circulation  in 
infancy  and  adolescence,  rev.,  465. 

Keetley,  C.  B.,  F.R.C.S.,  on  the  surgery 
of  the  knee-joint,  rev.,  840. 

Kellgren,  Dr  Arwid,  484. 


1889.] 


INDEX. 


1169 


Kerr,  Norman,  M.D.,  inebriety,  its  etio- 
logy, pathology,  treatment,  and  juris- 
prudence, rev.,  162. 

Klein,  E.,  M.D.,  elements  of  histology, 
rev.,  1129. 

Knee-joint,  antiseptic  irrigation  of  the,  80. 

Kreochyle,  183. 

Kreuznach  mother  liquor  and  chloride  of 
calcium  in  the  treatment  of  skin  diseases, 
176. 

KuHN,  Dr,  I'enseignement  et  I'organisation 
de  I'art  dentaire  aux  etats-unis,  rev.,  740. 


Labia  minora  and  hymen,  by  J.  W.  Ballan- 
tyne,  M.D.,  425. 

Labour,  the  third  stage  of,  by  A.  H.  F. 
Barbour,  M.D.,  97;  an  improved  method 
of  managing  the  third  stage  of,  by  D.  B. 
Hart,  M.D.,  289;  physiology  of  third 
stage  of,  by  T.  A.  Helme,  M.B.,  612; 
treatment  of  third  stage  of,  853. 

Lang,  W.  Soott,  M.D.,  abstract  of  intro- 
ductory lecture,  489;  notes  on  a  case  of 
femoral  hernia  met  with  in  the  dead  sub- 
ject, 785 ;  a  case  of  primary  sarcoma  of 
the  liver,  904. 

Lange,  Dr  C,  ueber  gemiithsbewegungen, 
rer.,  346. 

Lanoline,  toilet,  583. 

Laparotomy,  twelve  cases  of,  for  disease  of 
the  uterine  appendages,  by  N.  T.  Brewis, 
M.D.,  117;  successful,  after  extensive 
injury  to  the  intestines,  578;  results  of, 
for  acute  obstruction,  966. 

Laryngeal  carcinoma,  859,  861. 

Laryngology  and  rhinology,  periscope  of, 
by  J.  Maxwell  Ross,  F.K.C.S.,  382. 

Larynx,  clinical  notes  on  fatty  tumours  of 
the,  by  P.  M' Bride,  M.D.,  703. 

Lawson,  Robert,  LL.D.,  on  epidemic 
influences,  rev.,  248. 

Lecture,  Dr  Scott  Lang's  introductory,  489. 

Leftwich,  R.  W.,  M.D.,  an  index  of  symp- 
toms as  an  aid  to  diagnosis,  rev.,  465. 

Leifert,  Otto,  and  Friedrich  MBller, 
manual  of  clinical  diagnosis,  rev.,  547. 

Lesser's  atlas  der  gerichtlichen  medicin,  582. 

Leukoplakia  buccalis,  569. 

Lewers,  Arthur  H.  N.,  M.D.,  a  practical 
text-book  of  the  diseases  of  women,  rev., 
546. 

Lewis's  medical  and  scientific  library,  cata- 
logue of,  rev.,  552. 

Lichen  ruber,  acuminatus,  763  ;  as  observed 
in  America,  and  its  distinction  from  lichen 
planus,  958. 

Limbs,  artificial,  by  0.  W.  Cathcart,  M.B., 
819. 

Liquors,  concentrated,  183. 

Littlejohn,  Harvey,  M.B.,  notes  of  a 
case  of  transposition  of  the  abdominal  and 
thoracic  viscera,  907. 

Liver,  a  case  of  primary  sarcoma  of  the,  by 
W.  Scott  Lang,  M.D.,  904. 

Longmore,  Surg.-Gen.  Sir  T.,  the  illus- 
trated optical  manual,  rev.,  549. 

Lupus,  in  north  of  France,  764;  treatment 
of  minute  nodules  of,  after  the  mass  of  the 
deposit  has  been  got  rid  of,  764 ;  of  the 
tongue,  1156. 

EDINBURGH   MED.    JOURN.,    VOL. 


Mc 

M'Bride,  p.,  M.D.,  methods  of  treating 
nasal  and  naso-pharyngeal  polypi.  111 ; 
clinical  notes  on  fatty  tumours  of  the 
larynx,  703. 

MacCormac,  Sir  William,  surgical  opera- 
tions, part  ii.,  rev.,  1131. 

M'CuLLOCH,  Dr  Ja8.  Murray,  obituary,  188. 

Macdonald,  Greville,  M.D.,  board-school 
laryngitis,  rev.,  1131. 

M'Kendrick,  Prof.  J.  Gray,  a  text-book  of 
physiology,  rev.,  55. 

Mackenzie,  G.  Hunter,  M.D.,  cases  of 
endo-laryngeal  removal  of  growths  from 
the  vocal  cords,  36  ;  the  influence  of  cer- 
tain medicinal  agents  on  the  bacillus  of 
tubercle  in  man,  596  ;  le  crachat,  rev.,  649. 

Mackenzie,  Sir  Morell,  the  fatal  illness 
of  Frederick  the  Noble,  rev.,  541 ;  on  the 
treatment  of  acute  and  chronic  tonsillitis, 
676. 

Maclaren,  James,  F.R.C.S.E.,  obituary, 
1070. 

Maclaurin,  H.  N.,  M.D.,  comparative 
view  of  the  mortality  of  different  colonies 
from  certain  diseases,  rev.,  1041,  1070. 

Macnamara,  Rawdon,  an  introduction  to 
the  study  of  the  British  pharmacopoeia, 
rev.,  348. 

M'Vail,  John  0.,  M.D.,  vaccination  vindi- 
cated, rev.,  34. 


M 


Mackness,  G.  Owen  U.,  B.A.,  some  scarla- 
tiniform  rashes  occurring  during  the  puer- 
perium,  134 ;  on  the  relative  weights  of 
the  placenta  and  child,  716. 

Maddox,  R.  H.,  and  G.  O.  C.  Mackness, 
report  of  the  Royal  Maternity  and  Simp- 
son Memorial  Hospital,  238. 

Malaria,  foetal,  as  illustrated  by  two  cases, 
by  R.  W,  Felkin,  M.D.,  1101. 

Marckwald,  M.,  M.D.,  the  movements  of 
respiration  and  their  innervation  in  the 
rabbit,  rev.,  253. 

Martin,  Christopher,  and  John  G.  Have- 
lock,  report  of  the  Royal  Maternity  and 
Simpson  Memorial  Hospital,  317. 

Martin,  J.  W.,  M.D.,  cystic  disease  of  the 
ovaries,  435. 

Maternity,  Royal,  and  Simpson  Memorial 
Hospital,  report  of,  by  R.  H.  Maddox  and 
C.  G.  0.  Mackness,  238;  by  C.  Martin 
and  J.  G.  Havelock,  317. 

Matheson,  a.  a.,  M.D.,  a  case  of  rupture 
of  the  uterus,  713. 

Medical  periscope,  by  F.  Troup,  M.D.,  278, 
374,  479,  562,  954,  1151. 

Medicine  and  money,  94. 

Medicine  and  quackery,  by  James  Allan 
Gray,  M.D.,  393. 

Menstruation,  facts  relative  to,  by  James 
Oliver,  M.D.,  998. 

Mercury  nitrate  ointment  as  an  abortifacient 
of  boils  and  felons,  278. 

Meric,  H.  de,  notes  on  venereal  diseases, 
rev.,  1130. 

Merycismus,  279. 

Mickle,  W.  Julius,  M.D.,  the  Goulstonian 
lectures  on  insanity  in  relation  to  cardiac 
and  aortic  disease  and  phthisis,  rev.,  347. 

XXXIV.— NO.    XII.  7  I 


1J70 


INDEX. 


[1888- 


Middlesex  Hospital  reports  for  1886,  rev., 
60 ;  for  1887,  rev.,  1040. 

Miller,  A.  G.,  F.U.C.S.  Ed.,  surgical  peri- 
scope, 80,  386,  577,  965;  clinical  report  of 
case,  1031. 

Mills,  B.  Langlhy,  F.R.C.S.  Ed.,  a  case 
of  parasitic  foetus,  116, 

Mineral  waters,  391. 

Monstrosity,  dissection  of  a,  by  J.  Stuart 
Nairne,  813. 

Moon,  D.  Steele,  L.R.C.P.  &  S.  Ed.,  case  of 
peritonitis  following  perforation  of  the 
appendix,  131. 

MORI30N,  Albert  E.,  M.B.,  case  of  extra- 
uterine gestation,  236. 

MoRisoN,  Rutherford,  M.D.,  notes  of  a 
year's  work  in  abdominal  surgery,  40, 
146. 

MoRLEY,  H.  FoRSTER,  M.  A.,  Watt's  diction- 
ary of  chemistry,  rev.,  61. 

Morphine  in  diabetes  mellitus,  757 ;  a  new 
antidote  for,  1065. 

Morten,  Hon.nor,  sketches  of  hospital  life, 
rev.,  257. 

Moussena,  a  new  taenicide,  953. 

MuNRO,  Dr,  Ratho,  obituary,  972. 

Murray,  R.  Milne,  M.B.,  on  the  eflfects  of 
compression  of  the  foital  skull,  with 
special  reference  to  delivery  in  minor 
degrees  of  flat  pelvis,  417 ;  chemical  notes 
and  equations,  i-ev.,  551. 

N 

Nairne,  J.  Stuart,  F.F.P.S.,  dissection  of 
a  monstrosity,  813. 

Naismith,  W.  J.,  M.D.,  the  principles  of 
nursing,  rev.,  1039. 

Napier,  A.  D.  Leitii,  M.D.,  the  relation- 
ship between  neuralgia  and  abortion,  707. 

Narceine  in  whooping-cough,  73. 

Narcosis,  a  new  method  of  producing,  559. 

Narcotics,  method  of  testing,  by  Dr  Ottomar 
Rosenbach,  76. 

Nasal  fibromata,  385. 

Navy  medical  department,  369. 

Nephro-lithotomy,  92. 

Nestle's  milk  food,  390. 

Neuralgia,  butyl-chloral  in  trigeminal, 
1061. 

Neuritis,  a  case  of  multiple,  in  a  woman,  of 
combined  syphilitic  and  alcoholic  origin, 
by  Andrew  Smart,  M.D.,  19, 

Neuroses,  on  some  undescribed  respiratory, 
by  Andrew  Smart,  M.D.,  529;  on  certain 
vaso-motor,  by  G.  A.  Gibson,  M.D.,  531. 

Neve,  Arthur,  F.R.C.S.E.,  on  the  spon- 
taneous extrusion  of  sequestra,  519. 

Newman,  David,  M.D.,  lectures  to  practi- 
tioners on  the  diseases  of  the  kidney 
amenable  to  surgical  treatment,  rev.,  646. 

Night-sweats,  treatment  of,  by  the  external 
use  of  chloral,  1061. 

Nitro-benzol  poisoning,  amblyopia  in,  964. 

Nitro-glycerine,  951. 

Noma  in  the  Elizabeth  Children's  Hospital, 
St  Petersburg,  282. 

O 

Obituary  notices  of — Archibald,  Dr,  St 
Andrews,  970 ;  Bell,  Dr  George 
"William,  772;  Bonthron,  Dr,  of  West 


Linton,  972;  Combe,  Deputy  Surgeon- 
general,  969;  Dewar,  Dr  William, 
Kirkcaldy,  971;  Ddff,  George,  M.A., 
M.D.,  Elgin,  773  ;  Fothergill,  Dr  John 
Milner,  184;  Harvky,  Dr  Alex.,  1160; 
Inglis,  Archibald,  M.D.,  771 ;  M'Laren, 
James,  F.R.C.S.E.,  1070;  Munro,  Dr, 
Ratho,  972;  Paterson,  Dr  R,,  Leith, 
1159 ;  Poinset,  Dr  Georges,  of  Bor- 
deaux, 973;  Sinclair,  Dr  A.  J.,  969; 
Thom,  Dr  Alex.,  Crieff,  191;  Turton, 
Surgeon-major  F.  A.,  1163;  Watson, 
Dr,  Montrose,  1163 ;  Wylie,  David, 
L.R.C.S.E.,  1162. 

Obstetrical,  Edinburgh,  Society,  Jubilee, 
863. 

Obstetrics,  early  contributions  of  anatomy 
to,  by  A.  H.  F.  Barbour,  M.D.,  227,  328, 
450, 

CEdema,  solid  and  persisting,  of  eyelids  and 
face,  572, 

ffisophagotomy  for  removal  of  foreign  body, 
966, 

Ogle,  John  W.,  M.A.,  M.D,,  on  the  relief 
of  excessive  and  dangerous  tympanitis  by 
puncture  of  the  abdomen,  rev.,  1129. 

Oil,  iodised,  182, 

Oliver,  James,  M.D.,  notes  on  diseases  of 
women,  rev.,  646 ;  encysted  serous  peri- 
tonitis, 728;  facts  relating  to  menstrua- 
tion, 998. 

Ophthalmia,  purulent,  of  infants,  89, 

Ophthalmology,  periscope  of,  by  G,  A. 
Berry,  M.B.,961. 

Opium  in  diabetes  mellitus,  757, 

Orbit,  spontaneous  haematoma  of  the,  963. 

Osteoclast,  the,  as  a  means  of  redressing 
deformities  of  limbs,  by  K.  M.  Douglas, 
M.B.,  916. 

Osteotomy,  broad  chisels  in,  859, 

Otitis,  syphilitic,  575. 

Ovaries,  cystic  disease  of  the.  by  J,  W, 
Martin,  M.D.,  435. 

Ovariotomy,  second,  on  the  same  patient, 
564. 

Ozaena,  bacteria  of,  481. 


Pairman,   T,    Wyld,  L.R,C.P.  &  S.Ed., 

the  treatment  of  diphtheria  in  children  by 

steam  medicated  with  sulphurous    acid, 

724. 
Palate,  adeno-chondroma  of,  858. 
Papain  as  a  digestive  ferment,  952, 
Paraldehyde  in  obstinate  vomiting,  477. 
Paraplegia,  case  of  reflex  spastic,  under  the 

care  of  Dr  Affleck,  1118. 
Parker,  R.  Wm.,   M.R.C.S.,  tracheotomy 

in  children,  why  unsuccessful,  410. 
Parthenicin,  73. 
Pastes,  761. 
Paterson,    Dr  Robert,    Leith,    obituary 

notice,  1159. 
Pathological  Society  of  London,  transactions 

of,  vol.  xxxviii.,  rev.,  473  ;  general  index 

for  vols,  xxxi,  to  xxxvii.,  rev.,  474. 
Paton,    D.   Noel,    M.  D.,    the   systematic 

examination  of  the  urine  for  proteids,  522. 
Payne,  Joseph  Prank,  M.D.,  a  manual  of 

general  pathology,  rev.,  640. 
Pelvic  abscess,  the  treatment  of,  564. 


1889.] 


INDEX. 


1171 


Pelvic  floor,  a  contribution  to  the  normal 
anatomy  of  the  female,  by  Johnson 
Symington,  M.D.,  788;  the  nature  and 
aim  of  investigations  on  the  structural 
anatomy  of  the  female,  by  D.  B.  Hart, 
M.D.,  1095. 
Pemphigus  with  milium  in  cicatrices,  and 

arsenical  pigmentation,  762. 
Penis,  case  of  traumatic  gangrene  of,  and 
scrotum,  by  W.  Fergusson,  M.D.,  527. 

Pericaecal  inflammation,  morbid  anatomy  of, 
386. 

Peritonitis,  case  of,  following  perforation  of 
the  appendix,  by  D.  S.  Moon,  L.R.C.P., 
131;  encysted  serous,  by  James  Oliver, 
M.D.,  728. 

Pettigrew,  Prof.  J.  Bell,  M.D.,  the 
Harveian  oration  for  1889,  977,  1073. 

Phenacetin,  1062,  1069. 

Philadelphia,  sewerage  of,  956 ;  transactions 
of  the  College  of  Physicians  of,  rev.,  57. 

Philip,  K.  W.,  M.D.  ,  occasional  periscope 
of  tuberculosis,  by,  179. 

Phthisis,  the  diagnosis  of  early,  by  the 
microscope,  by  Francis  Troup,  M.D.,  1; 
the  treatment  of,  179;  the  hypodermic 
injection  of  antiseptic  substances  in  pul- 
monary, 180 ;  the  contagiousness  of,  182 ; 
case  of  acute,  with  large  cavities,  in  an 
infant  nursed  by  a  phthisical  mother,  by 
John  Thomson,  M.I).,  326;  kreosote  in, 
562 ;  Wesener  on  the  antiparasitic  treat- 
ment of,  1151. 

Physician,  the,  a  naturalist,  a  graduation 
address,  by  Prof.  Sir  W.  Turner,  193. 

Physicians,  Royal  College  of,  Edinburgh, 
182,  288,  484,  582,  679,  769,  880, 968,  1068. 

Physostigniine,  the  treatment  of  chorea 
with,  277. 

Pick,  T.  Pickeuing,  F.R.C.S.,  Holmes' 
surgery,  rev.,  840. 

Picrotoxin  in  epilepsy,  951. 

Pityriasis  pilaris,  1156. 

Placenta,  on  the  relative  weights  of,  and 
child,  by  G.  O.  Mackness,  B.A.,716;  a 
contribution  to  the  pathology,  symptoms, 
and  treatment  of  adherent,  by  D.  Berry 
Hart,  M.D.,  816;  concerning  a  certain 
kind  of  retention  of  the,  850 ;  expectant 
method,  or  Crede  manipulation  of  the,  851 ; 
note  on  some  anomalous  cases  of  separa- 
tion and  expulsion  of  the,  before  the  birth 
of  the  child,  by  D.  Berry  Hart,  M.D.,  900. 

Pleural,  serous,  effusion,  an  abstract  of  24 
cases  of,  treated  by  pneumatic  aspiration, 
by  J.  P.  Bramwell,  M.D.,  909. 

Pneumonia  crouposa  "  a  frigore,"  283. 

PoiNSET,  Dr  Georges,  of  Bordeaux, 
obituary,  973. 

Polypi,  methods  of  treating  nasal  and  naso- 
pharyngeal, by  P.  M'Bride,  M.D.,  111. 

Pott's  fracture,  966. 

Pregnancy,  vomiting  of,  566 ;  on  the  indica- 
tions for  primary  laparotomy  in  cases  of 
tubal,  567  ;  early  diagnosis  of  ectopic,  567. 

Psoriasis,  treatment  of,  379. 

Ptomaines  and  suppuration,  83. 

Puerperium,  some  scarlatiniform  rashes 
occurring  during  the,  by  G.  Owen  C. 
Mackness,  B.  A.,  134 ;  by  C.  P.  A.  Osburne 
(correspondence)  ,391. 


Pylorus,  congenital  stenosis  of  the,  in  chil- 
dren, 672. 
Pyrodine,  a  new  antipyretic,  951. 

Q 

Quinine,  bullous  eruption  produced  by,  763. 
Quinoline,  a  new  antiseptic,  476. 

R 

Ranney,  Ambrose  L.,  M.D.,  the  applied 
anatomy  of  the  nervous  system,  rev.,  345. 

Rectum,  excision  of  the  cancerous,  81. 

Relapsing  fever  in  children,  283. 

Retro -pharyngeal  abscess,  1065. 

Reviews  :—Allingham,  Wm.,  F.R.C.S., 
diseases  of  the  rectum,  550 ;  Anderson, 
J.  Walkbr,  M.D.,  the  essentials  of 
physical  diagnosis  of  the  chest  and 
abdomen,  1125;  Bakek,  Henky  B., 
M.D.,  malaria,  and  the  causation  of 
periodic  fever,  931  ;  Bartholow, 
Robert,  M.A.,  M.D.,  a  practical  treatise 
on  materia  medica  and  therapeutics,  58 ; 
Bennett,  Prof.  E.  H.,  the  sectional 
anatomy  of  congenital  caecal  hernia,  469  ; 
Bottentuit,  Dr,  the  waters  of  Plombieres, 
348;  Braitiiwaite,  Jas.,  M.D.,  the 
retrospect  of  medicine,  744  ;  Bridger,  A. 
E.,  M.D.,  the  demon  of  dyspepsia,  642 ; 
Bristowe,  J.  S.,  M.D.,  clinical  lectures 
and  essays  on  diseases  of  the  nervous 
system,  931 ;  Brocq,  Dr,  de  la  dermatite 
herp^tiform  de  Duhring,  928  ;  Brod- 
hurst,  Bernard  E.,  F.R.C.S.,  on  cur- 
vatures and  diseases  of  the  spine,  742  ; 
Brown,  W.  Symington,  M.D.,  a  clinical 
handbook  on  the  diseases  of  women,  741 ; 
Bruck,  LuDWiG,  a  guide  to  the  health 
resorts  in  Australia,  Tasmania,  and  New 
Zealand,  256;  Bryant,  Thomas,  F.R.C.S., 
Hunterian  lectures,  841 ;  Bui.len,  M.  W., 
and  A.  H.,  a  dialogue  against  the  fever 
pestilence,  246;  Buxton,  D.  AV.,  M.D., 
anesthetics,  their  uses  and  administration, 
471 ;  Byford,  Prof.  W.  H.,  the  practice 
of  medicine  and  surgery  applied  to  the 
diseases  and  accidents  incident  to  women, 
544 ;  Caird,  John,  D.D.,  mind  and 
matter,  651 ;  Campbell,  C.  M.,  M.D.,  the 
skin  diseases  of  infancy  and  early  life, 
1036  ;  Carter,  Alfred,  M.D.,  elements 
of  practical  medicine,  642 ;  Christie,  D., 
L.R.C.P.  &  S.  Ed.,  report  of  medical 
missionary  work  in  Manchuria,  258 ; 
Cleland,  Prof.  J.,  memoirs  and  memo- 
randa in  anatomy,  935 ;  Coats,  Joseph, 
M.D.,  on  the  pathology  of  phthisis  pul- 
monalis,  538 ;  Collier,  W.,  M.D.,  hydro- 
phobia, a  review  of  Pasteur's  treatment, 
650;  Crocker,  H.  R.,  M.D.,  diseases  of 
the  skin,  250;  Croft,  John,  F.K.C.S., 
internal  urethrotomy,  255 ;  Dale,  Ridley, 
M.  D.,  epitome  of  surgery,  1037;  Davies, 
George,  physiological  diagrams  for 
use  in  schools,  1129;  Donaldson,  S. 
James,  M.D.,  contributions  to  prac- 
tical gynaecology,  646;  Doran,  Alban 
H.  G.,  handbook  of  gynaecological  opera- 
tions, 1038;  Duncan,  Andrew,  M.D., 
the  prevention  of  disease  in  tropical  and 
sub-tropical    campaigns,    548 ;    Ebstein, 


1172 


INDEX. 


[1888- 


Prof.  W.,  la  goutte  sa  nature  et  son 
traitement,  648;  Esmarch,  Dr  F.  von, 
the  surgeon's  handbook,  252;  Everett, 
Gkaham,  doctors  and  doctors,  62;  Fayker, 
Sir  Joseph,  the  natural  history  and  epi- 
demiology of  cholera,  256;  Pen  wick,  E. 
H.,  F.R.C.S.,  the  electric  illumination  of 
the  bladder  and  urethra,  255;  F^ufi,  Cii., 
cancer  de  la  vessie,  640 ;  Flint,  Austin, 
M.D.,  a  text-book  of  human  physio- 
logy, 1 128 ;  Fort,  Professor  LgoN 
LE,  manuel  de  m^decine  op^ratoire 
de  J.  F.  Malgaigne,  59;  Foster,  Prof. 
M.,  a  text-book  of  physiology,  540 ; 
FuRNiVALL,  F.  J.,  the  anatomic  of  the 
bodie  of  man,  247 ;  Gairdner,  Prof.  W. 
T.,  on  the  diseases  classified  by  the 
Registrar-General  as  tabes  mesenterica, 
538 ;  the  physician  as  naturalist,  927 ; 
GiLLiNGHAM,  James,  artificial  limbs, 
surgical  appliances,  etc.,  470;  Gordon, 
G.  A.,  M.D.,  comments  on  the  report  of 
the  committee  on  M.  Pasteur's  treatment 
of  rabies  and  hydrophobia,  343 ;  Gouley, 
J.  W.  S.,  M.D.,  the  diseases  of  man,  467; 
Greville,  H.  L.,  F.I.C,  the  student's 
handbook  of  chemistry,  161 ;  Griffiths, 
W.  Handsel,  Ph.D.,  lessons  on  prescrip- 
tions and  the  art  of  prescribing,  58;  Guy's 
and  Ferriek's  principles  of  forensic  medi- 
cine, 937;  Haig,  A.,  M.D.,  the  formation 
and  excretion  of  uric  acid  considered 
with  reference  to  gout  and  allied  dis- 
eases, 936;  Harris,  Vincent  D., 
M.D.,  the  diseases  of  the  chest,  1125; 
Harrison,  Reginald,  F.R.C.S.,  lectures 
on  the  surgical  disorders  of  the  urinary 
organs,  59 ;  Hewer,  Annie  M.,  antiseptics, 
a  handbook  for  nurses,  1040 ;  Higgins, 
Charles,  F.R.C.S.E.,  a  manual  of  oph- 
thalmic practice,  550 ;  Holden,  Luther, 
landmarks,  medical  and  surgical,  347 ; 
Hovell,  T.  Mark,  F.R.C.S.E.,  on  the 
treatment  of  cystic  goitre,  743 ;  Huchard, 
Henri,  quand  et  comment  doit-on  prescrire 
la  digitale,  650;  Hummei>,  A.  L.,  univer- 
sity medical  magazine,  745;  Husband,  II. 
Aubrey,  M.B.,  the  student's  handbook  of 
the  practice  of  medicine,  546 ;  the  student's 
handbook  of  forensic  medicine  and  public 
health,  937;  Hyde,  James  N.,  M.D.,  a 
})ractical  treatise  on  diseases  of  the  skin, 
250;  Jacobson,  W.  H.,  M.B.,  the  opera- 
tions of  surgery,  933 ;  James,  Alexander, 
M.D.,  physiological  and  clinical  studies, 
154;  pulmonary  phthisis,  its  etiology, 
pathology,  and  treatment,  1123;  Johnston, 
George,  M.D.,  medical  lectures  and 
essays,  464;  Jones,  Joseph,  M.D., medical 
and  surgical  memoirs,  1126;  Keating,  J. 
M.,  and  W.  A.  Edwards,  diseases  of  the 
heart  and  circulation  in  infancy  and  ado- 
lescence, 465;  Keetley,  C.  B.,  F.R.C.S., 
the  surgery  of  the  knee-joint,  840 ;  Kerr, 
Norman,  M.D.,  inebriety,  its  etiology, 
pathology,  treatment,  and  jurispru- 
dence, 162;  Klein,  E,,  M.D.,  elements 
of  histology,  1129;  Kuhn,  Dr,  I'en- 
seignement  et  1 'organisation  de  I'art 
dentaire  aux  €tats-unis,  740;  Lange, 
Dr  C,  ueber  gemiithsbewegungen,  346; 


Lawson,  Robert,  LL.D.,  on  epidemic 
influences,  248 ;  Leftwicii,  R.  W.,  M.U., 
an  index  of  symptoms  as  an  aid  to  diagnosis, 
465 ;  Leifert,  Otto,  and  Fkiedrich 
MuLLER,  manual  of  clinical  diagnosis,  547  ; 
Leweks,  Arthur,  H.  N.,  M.D.,  a  prac- 
tical text-book  of  the  diseases  of  women, 
546;  LoNGMORE,  Surgeon-General,  the 
illustrated  optical  manual,  549 ;  Mac- 
CoRMAC,  Sir  William,  surgical  opera- 
tions, part  ii.,  1131;  Macdonald, 
Greville,  M.D.,  board-school  laryngitis, 
1131;  M'Kendrick,  Prof.  J.  Gray, 
a  text-book  of  physiology,  55 ;  Mac- 
kenzie, G.  Hunter,  M.D.,  le  crachat, 
649;  Mackenzie,  Sir  Morell,  the 
fatal  illness  of  Fi-ederick  the  Noble, 
541;  Maclaurin,  H.  N.,  M.D.,  compara- 
tive view  of  the  mortality  of  different 
colonies  from  certain  diseases,  1041  ;  M  ac- 
namara,  Rawdon,  an  introduction  to  the 
study  of  the  British  Pharmacopoeia,  348 ; 
M'Vail,  John  C,  M.D.,  vaccination  vin- 
dicated, 342;  Marckwald,  M.,  M.D.,  the 
movements  of  respiration  and  their  inner- 
vation in  the  rabbit,  253  ;  Meric,  H.  de, 
notes  on  venereal  disease,  1130;  Mickle, 
W.  Julius,  M.D.,  the  Goulstonian  lectures, 
on  insanity  in  relation  to  cardiac  and 
aortic  disease  and  phthisis,  347  ;  Morley, 
H.  Forsteh,  M.A.,  Watt's  dictionary  of 
chemistry,  61 ;  Morten,  Honnor,  sketches 
of  hospital  life,  257;  Murray,  R.  Milne, 
M.  B.,  chemical  notes  and  equations,  551 ; 
Naismith,  W.  J.,  M.D.,  the  principles 
of  nursing,  1039;  Newman,  David, 
M.D.,  lectures  to  practitioners  on  the 
diseases  of  the  kidney  amenable  to 
surgical  treatment,  646 ;  Ogle,  John  W., 
M.D.,  on  the  relief  of  excensive  and 
dangerous  tympanitis  by  puncture  of 
the  abdomen,  1129 ;  Oliver,  James, 
M.D.,  notes  on  diseases  of  women, 
646;  Payne,  Joseph  Frank,  M.D., 
a  manual  of  general  pathology,  640 ; 
Pick,  T.  Pickering,  F. K.U.S.,  Holme's 
surgery,  840 ;  Ranney,  Ambrose  L., 
M.D.,  the  applied  anatomy  of  the  nervous 
system,  345;  Richardson,  Benj.  Ward, 
the  son  of  a  star,  652  ;  the  asclepiad,  940  ; 
Ringer,  Prof  Sydney,  M.D.,  a  handbook 
of  therapeutics,  551;  Ruata,  Professor 
(Jaklo,  difendetevi  dalla  febbre  tifoidea, 
643;  Saundby,  RoBEKT,M.B.,  lectures  on 
Bright's  disease,  1035 ;  Simon,  R.  M., 
M.D.,  lectures  on  the  treatment  of 
the  common  diseases  of  the  skin,  466; 
Skene,  Alexander  J.  C,  M.D., 
treatise  on  the  diseases  of  women,  1037 ; 
Stewart,  Prof.  T.  Grainger,  clinical 
lectures  on  important  symptoms,  152 ; 
Stimson,  Lewis  A.,  B.A.,  a  treatise  on 
dislocations,  468 ;  Stoker,  George,  de- 
viations of  the  nasal  septum,  742;  Styrap, 
Jukes  de,  the  medico-chirurgical  tariffs 
prepared  for  the  late  Shropshire  ethical 
branch  of  the  British  Medical  Association, 
62;  SwANZY,  H.  R.,  M.B.,  a  handbook  of 
the  diseases  of  the  eye,  346 ;  Thompson, 
Sir  Henry,  diseases  of  the  urinary  organs, 
838  ;  on  the  preventive  treatment  of  cal- 


1889.] 


INDEX. 


1173 


culous  disease  and  the  use  of  solvent 
remedies,  839;  Tripjeu,  Prof.  R.,  la  fifevre 
typhoide  trait^e  par  les  bains  froids,  6.50 ; 
Tucker,  G.  A.,  lunacy  in  many  lands, 
155;  TuKE,  J.  Batty,  and  G.  Sims  Wood- 
head,  reports  from  the  laboratory  of  the 
Koyal  College  of  Physicians,  Edinburgh, 
1127;  ViEROKDT,  Dr  Hermann,  anato- 
mische,  physiologische,  und  physikalische 
daten  und  tabellen  zum  gebrauche  fiir 
mediciner,  469 ;  Wallace,  Professor 
KoBEKT,  India  in  1887,  161;  Warf- 
yiNGE,  Dr  P.  W.,  record  of  practice 
in  the  hospital  at  iSabbetsberg  at  Stock- 
holm for  1887,  735 ;  Williams,  C.  J.  b., 
and  C.  T.,  pulmonary  consumption, 
461 ;  Williams,  W.  R.,  F.R.C.S.,  the 
principles  of  cancer  and  tumour  for- 
mation, 638;  WiNCKEL,  Dr  F.,  diseases 
of  women,  647 ;  Windle,  Prof.  B.  C.  A., 
a  handbook  of  surface  anatomy  and  land- 
marks, 935;  Wise,  A.  Tucker,  M.D., 
Alpine  winter  in  its  medical  aspects,  743 ; 
Wolfenden,  R.  Norkis,  M.l).,  and  Sid- 
mey  Martin,  M.D.,  studies  in  pathological 
anatomy,  641 ;  Wood,  Prof.  H.  C.,  thera- 
peutics, its  principles  and  practice,  651. 

Reviews : — Annales  de  dermatologie  et  de 
syphiligraphie,  930 ;  medico-chirurgicales, 
Dec.  1887,  58  ;  annals  of  surgery  for  June 
,1€88,  159;  for  Sept.  1888,  46G ;  diary, 
the  ABC  medical,  and  visiting  list,  653  ; 
dictionary,  an  illustrated  encyclopaedic 
medical,  938 ;  dispensing,  the  art  of,  551 ; 
Fletcher's  new  patent  calendar  for  1889, 
841 ;  Guy's  Hospital  reports,  841 ;  Lewis's 
medical  and  scientific  library,  catalogue 
of,  552;  Middlesex  Hospital  reports  for 
1886,  60;  for  1887,  1040;  St  Thomas's 
Hospital  reports,  vol.  xvi.,  472;  Scots 
Observer,  940  ;  Student,  the,  Nos.  7,  8,  9, 
1041;  Transactions  of  the  American  Gynae- 
cological Society,  vol.  xiii.,  1039;  of 
the  Association  of  American  Physicians, 
475  ;  of  the  College  of  Physicians  of  Phila- 
delphia, 57  ;  of  the  New  York  State 
Medical  Association,  vol.  iii.,  474;  of  the 
Pathological  Society  of  London,  vol. 
xxxviii.,  473 ;  unofficial  formulary  B.P.C., 
161;  Vanguard,  the,  May  1888,  63;  what 
can  I  do  to  get  well  ?  and  how  can  I  keep 
so?  1132;  year-book  of  treatment  for  1889, 
940. 

Rheumatism,  cascara  sagrada  in,  559. 

Richardson,  Benjamin  Ward,  the  son  of  a 
star,  rev.,  652;  the  asclepiad  for  the  first 
quarter,  1889,  rev.,  940. 

Ringer,  Prof.  Sidney,  M.D.,  a  handbook 
of  therapeutics,  rev.,  551. 

Ritchie,  Dr  Peel,  notes  on  report  of  the 
departmental  committee  appointed  to  in- 
quire into  pleuro-pneumonia  and  tuber- 
culosis in  the  United  Kingdom,  617, 
693. 

Roberts,  F.  T.,  M.D.,  a  handbook  of  the 
theory  and  practice  of  medicine,  rev., 
464. 

Roberts,  R.  Lawson,  M.D.,  illustrated  lec- 
tures on  ambulance  work,  rev.,  743. 

Robertson,  G.  J.,  M.U.,  empyaema,  rev., 
649. 


Rolland,  Dr  E.,  de  I'epilepsie  Jaoksonni- 

enne,  rev.,  158. 
RoosE,   Robson,   M.D.,  nerve   prostration 

and  other  functional  disorders  of  daily  life, 

rev.,  465. 
Ross,  J.  Maxwell,  F.H.C.S.,  periscope  of 

laryngology  and  rhinology,  382. 
Ruata,  Prof.  Carlo,  difendetevi  dalla  febbre 

tifoidea,  rev.,  643. 
Rumination,  279,  375. 

S 

Saccharin,  soluble,  183. 

St  Thomas's  Hospital  reports,  vol.  xvi.,re»., 
472. 

Sanitary  arrangements  of  the  ancient  Hebrew 
camp  in  the  desert  and  the  modern  cities 
of  Manchester,  Edinburgh,  and  Liverpool, 
573. 

Saundby,  Robert,  M  .B., lectures  on  Bright 's 
disease,  rev.,  1035. 

Scarification,  quadrilateral  linear,  79. 

Sciatica,  antifebrin  in,  953;  antipyrin  in, 
1062. 

Scotland,  medical  schools  of,  358. 

Scots  Observer,  rev.,  940. 

Sections,  notes  on  Saexinger's  and  Winter's, 
by  A.  H.  Freeland  Barbour,  M.D.,  1091. 

Semmola,  Prof.  Mariano,  address  on  scien- 
tific medicine  and  bacteriology  in  refer- 
ence to  the  experimental  method,  336, 439. 

Sequestra,  on  the  spontaneous  extrusion  of, 
by  Arthur  Neve,  F.R.C.S.E.,  519. 

Sewerage  and  drainage  in  Philadelphia,  956. 

Sign-board,  original,  in  Burton's  old  curio- 
sity shop,  Falmouth,  183. 

Simon,  R.  M.,  M.D.,  lectures  on  the  treat- 
ment of  the  common  diseases  of  the  skin, 
rev.,  466. 

Sinclair,  Dr  A.  J.,  obituary,  969. 

"  Size,  about  the,  of  a ,"  94. 

Skene,  Alex.  J.  C,  M.D.,  treatise  on  the 
diseases  of  women,  rev.,  1037. 

Skin,  transplantation  of,  after  death,  481 ; 
review  of  cases  of  disease  of,  by  Dr  W. 
A.  Hardaway,  568. 

Skull,  on  the  effects  of  compression  of  the 
foetal,  with  special  reference  to  delivery 
in  minor  degrees  of  flat  pelvis,  by  R.  Milne 
Murray,  M.B.,  417. 

Smart,  Andrew,  M.D.,  a  case  of  multiple 
neuritis  in  a  woman,  19;  abstract  of  paper 
on  some  undescribed  respiratory  neuroses, 
529. 

Soaps  containing  salts  from  mineral  springs, 
570. 

Society,  meeting  of  British  Laryngological 
and  Rhinological. — Session  i. — Meeting  i. 
— Exhibition  of  patient  by  the  President ; 
exhibition  of  pathological  specimens  by 
Mr  Lennox  Browne,  Dr  Orwin,  and  Dr 
Dundas  Grant ;  exhibition  of  drawings  of 
microscopic  specimens  by  Dr  R.  N  orris 
Wolfenden;  presidential  address  by  Sir 
Morell  Mackenzie;  discussions  on  the 
treatment  of  nervous  diseases  of  the  throat, 
and  on  anosmia ;  papers  by  Drs  Hunter 
Mackenzie,  J.  M.  Hunt,  and  Greville 
Macdonald,  555. 

Society,  meetings  of  Carlisle  Medical,  475, 
756. 


1174 


INDEX. 


[1888- 


Society,  meetings  of  Medico-Chirurgical,  of 
Edinburgh. — Session  Ixvii. — Meeting  v. — 
Election  of  ordinary  member ;  exhibition 
of  patient  by  Mr  Cathcart;  demonstra- 
tions by  Mr  John  Duncan  and  Prof.  Chiene; 
exhibition  of  pathological  specimen  by  Dr 
A.  Bruce ;  discussion  on  Dr  Affleck's  paper 
on  the  clinical  value  of  temperature  ob- 
servations in  certain  acute  and  chronic 
diseases,  64. 

Meeting  vi.— Discussion  on  Mr  A.  G. 
Miller's  paper  on  three  cases  of  nephro- 
tomy; discussion  on  Dr  Smart's  paper  on 
some  forms  of  undescribed  respiratory 
neuroses,  69. 

Meeting  vii. — Exhibition  of  patient  by 
Prof.  T.  K.  Fraser  {illustrated) ;  discussion 
on  Dr  W.  W.  Ireland's  case  of  cerebral 
injury  from  a  fall;  discussion  on  DrDods's 
paper  on  tropical  malaria  and  its  sequelae, 
163. 

Meeting  will. — Discussion  on  Dr  Smart's 
case  of  multiple  neuritis ;  discussion  on 
Dr  Troup's  paper  on  the  diagnosis  of 
phthisis,  258. 

Meeting  ix. — Exhibition  of  patients  by 
Dr  (leo.  Mackay,  Prof.  Grainger  Stewart, 
Dr  Brakenridge,  and  Dr  Allan  Jamieson  ; 
exhibition  of  specimens  by  Drs  P.  H. 
Maclaren,  J.  M.  Cotterill,  Shaw  M'Laren, 
and  Prof  Grainger  Stewart ;  Dr  J.  M. 
Cotterill'h  paper  on  two  epidemics  of  sore 
throat  and  their  relation  to  the  milk  supply, 
and  discussion  thereon,  262. 

Meeting  x. — Exhibition  of  patient  by  Dr 
Allan  Jamieson  ;  exhibition  of  apparatus 
by  Dr  A.  Bruce,  Mr  F.  M.  Caird,  and  Dr 
Felkin ;  exhibition  of  specimens  by  Dr 
Byrom  Bramwell  and  Mr  A.  G.  Miller  ; 
discussion  on  Dr  M' Bride's  paper  on  the 
methods  of  removing  nasal  polypi ;  dis- 
cussion on  Dr  Alexander  Thom's  paper 
on  tracheotomy  in  children,  why  unsuc 
cessful,  349. 

Session  Ixviii. — Meeting  i. —  Election  of 
office-bearers ;  exhibition  of  patients  by 
Drs  M 'Bride,  Affleck,  and  Allan  Jamie- 
son; Dr  Peel  Ritchie's  notes  on  report 
of  the  departmental  committee  appointed 
to  inquire  into  pleuro-pneumonia  and 
tuberculosis  in  the  United  Kingdom,  552. 
Meeting  ii. — Election  of  new  members  ; 
exhibition  of  patient  by  Prof.  Grainger 
Stewart ;  exhibition  of  instrument  by  Dr 
J.  Foulis ;  exhibition  of  pathological 
specimens  by  Mr  Scott  Lang,  Prof.  Chiene, 
and  Mr  J.  M.  Cotterill ;  discussion  on  Mr 
J.  M.  Cotterill's  case  of  gangrene  in  the 
transverse  colon  in  an  umbilical  hernia,  653. 
Meeting  iii.—  Exhibition  of  pathological 
specimens  by  Mr  A.  G.  Miller,  Dr  Allan 
Sym,  and  Dr  James  Ritchie;  discussion 
on  Dr  T.  Wyld  Pairman's  paper  on  the 
treatment  of  diphtheria  in  children  by 
antiseptic  steam;  discussion  on  Dr 
M'Bride's  clinical  notes  on  lipomata  of  the 
larynx,  745. 

Meeting  iv.— Election  of  new  members; 
exhibition  of  specimens  by  Dr  A.  Bruce, 
Mr  F.  M.  Caird,  Dr  Francis  Troup,  and 
Dr  Philip ;  discussion  on  Dr  Felkin's  case 


of  elephantiasis;  discussion  on  Prof.  Annan- 
dale's  paper  on  the  removal  by  operation 
of  naso-pharyngeal  tumours  ;  discussion 
on  Dr  Philip's  paper  on  tuberculosis  of 
the  bladder  in  a  case  of  phthisis  pulmon- 
alis,  842. 

Meeting  v. — Election  of  new  members ; 
exhibition  of  instruments  by  Prof.  Annan- 
dale  ;  exhibition  of  specimens  by  Mr  A. 
G.  Miller  and  Dr  Lundie ;  discussion  on 
Mr  Cathcart's  paper  on  sites  for  ampu- 
tation in  the  lower  limb  in  relation  to  arti- 
ficial substitutes ;  discussion  on  Prof. 
Annandale's  paper  on  acute  intussuscep- 
tion in  a  child  three  years  of  age  success- 
fully relieved  by  abdominal  section,  941. 

Meeting  vi. — Discussion  on  the  question 
of  the  necessity  for  further  legislation  for 
the  care  of  habitual  drunkards,  1042, 1133. 
Society,  meetings  of  Edinburgh  Obstetrical. 
— Session  xlix.  —  Meeting  vii.  —  Exhibi- 
tion of  specimens  by  Dr  Thomas  Wood 
and  Dr  Barbour ;  discussion  on  Dr  Bar- 
bour's paper  on  early  contributions  to 
gynaecology  and  obstetrics,  71. 

Meeting  viii. — Exhibition  of  specimens 
by  Dr  Halliday  Groom ;  discussion  on  Dr 
Brewis's  paper  on  twelve  cases  of  laparo- 
tomy ;  discussion  on  Dr  Halliday  Croom's 
paper  on  the  retroflexed  gravid  uterus ; 
Dr  J.  W.  Ballantyne  on  the  labia  minora 
and  hymen,  171. 

Meeting  ix. — Exhibition  of  specimen  by 
Dr  Brewis ;  Dr  B.  Langley  Mills  on  a  case 
of  parasitic  foetus ;  discussion  on  Surgeon- 
Major  Arnott's  successful  case  of  Caesarean 
section  ;  Dr  A.  E.  M orison's  case  of  extra- 
uterine gestation;  historical  note  by  Dr 
A.  S.  Currie;  discussion  on  Dr  Milne 
Murray's  paper  on  the  eflfects  of  compres- 
sion of  the  shape  of  the  foetal  head,  172. 

Meeting  x. — Exhibition  of  specimens 
by  Dr  Brewis;  notice  of  patients  by  Dr 
Foulis ;  demonstration  of  the  action  of 
galvanic  currents  by  Dr  Milne  Murray; 
Dr  John  Thomson's  case  of  acute  phthisis  ; 
Dr  J.  W.  Martin  on  the  pathology  of 
cystic  ovaries,  274. 

Sessio7i  1.  Meeting  i. — Exhibition  of 
specimens  by  Dr  Sym,  Prof.  Simpson, 
Dr  Sinclair ;  presidential  address  by  Dr 
Underbill ;  discussions  on  Dr  Matheson's 
case  of  rupture  of  uterus,  and  on  Dr 
Helme's  paper  on  the  physiology  of  the 
third  stage  of  labour,  661. 

Meeting  ii. — Exhibition  of  specimens  by 
Prof.  Simpson,  Dr  Matheson,  Dr  Milne 
Murray,  and  Dr  Halliday  Croom;  discus- 
sion on  Dr  Berry  Hart's  contribution  to 
the  pathology,  symptoms,  and  treatment  of 
adherent  placenta;  Prof.  Simpson  on  Dr 
Owen  Mackness's  paper  on  the  relative 
weights  of  the  placenta  and  child ;  discus- 
sion on  Dr  Leith  Napier's  paper  on  the 
relationship  between  neuralgia  and  abor- 
tion, 750. 

Meeting  iii. — Exhibition  of  instrument 
by  Dr  Foulis;  exhibition  of  specimens  by 
Dr  Halliday  Croom;  discussion  on  papers 
by  Drs  Freeland  Barbour,  Johnson  Sym- 
ington, and  Berry  Hart,  946. 


1889.] 


INDEX. 


1175 


Meeting  iv. — Exhibition  of  specimens 
for  Dr  H.  Groom  ;  exhibition  of  mercuric 
pellets  by  Dr  Foul  is ;  discussion  on  Dr 
Felkin's  paper  on  fcetal  malaria;  discus- 
sion on  Dr  Barbour's  paper  on  the  light 
which  sectional  anatomy  will  throw  on  the 
mechanism  of  labour;  discussion  on  Dr 
Berry  Hart's  note  on  some  anomalous 
separations  of  the  placenta  prior  to  the 
birth  of  the  child,  1056. 

Meeting  v. — Exhibition  of  specimens  by 
the  President  and  Dr  Halliday  Groom  ; 
discussion  on  Dr  Halliday  Groom's  analysis 
of  one  hundred  and  twenty-eight  com- 
pleted cases  of  abdominal  section,  1143. 
Society,  meeting  of  the  Glasgow  Obstetrical 

and  Gynaecological,  G67. 
Society,  meetings  of  Itoyal  Medical,  557, 

668,  754,  846,  949,  1146. 
Soziodol,  485. 
State  medicine,  periscope  of,  by  J.  Allan 

Gray,  M.D.,  572,  956. 
Stewart,     Prof.     T.     Grainqek,    clinical 
lectures  on  important  symptoms,  rev.,  152. 
Stimson,  Lewis  A.,  B.A.,  a  treatise  on  dis- 
locations, rev.,  468. 
SxoKEK,   Geouge,   deviations  of  the  nasal 

septum,  rev.,  742. 
Strychnine,  parenchymatous  injection  of,  in 

enlarged  spleen,  476. 
Student,  the,  Nos.  7,  8,  9,  rev.,  1041. 
Styrap,  Jukes de,  M.K.Q.G.P.,  the medico- 
chirurgical   tariffs  prepared  for  the   late 
Shropshire  ethical  branch  of  the  British 
Medical  Association,  rev.,  62. 
Suicide,  case  of,  with  numerous  wounds,  956. 
Sulphonal,  75,  276,  278,  558,  671,  679,  1150. 
Surgeons,  Royal  Gollege  of,  Edinburgh,  182, 

288,  484,  769,  1069. 
Surgery,  occasional  periscope  of,  by  Edwin 

G.  Bull,  M.B.,  858. 
Surgical     periscope,    by     A.     G.    Miller, 

F.lc.G.S.  Ed.,  80,  386,  577,  965. 
SwANzy,  H.  H.,  M.B.,  a  handbook  of  the 

diseases  of  the  eye,  rev.,  346. 
Sycosis,  treatment  of,  380. 
Symington,  Johnson,  M.D.,  a  contribution 
to   the   normal   anatomy   of  the   female 
pelvic  floor,  788. 
Syphilis,  earliest  symptoms  of  inherited,  79; 
case  of,  affecting  larynx,  etc.,  followed  by 
pneumonia  and  phthisis,  89 ;  recognition 
of  unsuspected,  90 ;  the  present  position 
of  the  therapeutics  of,  177 ;   importance 
and  eradication  of,  483 ;  alleged  vaccinal, 
575;  an  address  on,  854;  as  a  non-venereal 
disease,  856. 
Syphilology,  periscope  of,  by  Francis  Cadell, 
F.K.G.S.  Ed.,  89,  482,  575,  854. 

T 

Talipes  equino-varus,  966. 

Taylor,  H.  Goupland,  M.D.,  personal 
experiences  of  a  winter  in  the  Canary 
Islands,  607. 

Temperature  observations,  the  clinical  value 
of,  in  some  acute  and  chronic  diseases,  by 
J.  0.  Affleck,  M.D.,  7. 

Therapeutics,  monthly  report  on  the  pro- 
gress of,  by  Dr  W.  Craig,  73,  276,  476, 
558,  669,  757,  951,  1061,  1149. 


Thom,  Dr  At.ex.,  sen.,  Crieff,  obituary, 
191. 

Thom,  Alexander,  M.D.,  tracheotomy  in 
children,  why  unsuccessful,  212. 

Thompson,  Sir  Henry,  diseases  of  the 
urinary  organs,  re?;.,  838;  on  the  preven- 
tive treatment  of  calculous  disease  and  the 
use  of  solvent  remedies,  rev.,  839. 

Thompson,  John,  M.B.,  case  of  acute 
phthisis,  with  large  cavities,  in  an  infant 
nursed  by  a  phthisical  mother,  326. 

Throat,  slight,  affections,  383. 

Thyme  in  whooping-cough,  73. 

Thyroid,  surgery  of  the,  81 ;  malignant 
tumour  of  the,  82;  bloodless  extirpation 
of  tumours  of  the,  858 ;  excision  of  dis- 
eased, 860. 

Tin,  noxious  salts  of,  in  fruits  prepared  in 
tin  vessels,  572. 

Tonsil,  chancre  of,  90. 

Tonsillitis,  treatment  of,  by  salicylate  of 
sodium,  382. 

Tonsils,  treatment  of  enlarged,  82. 

Tracheotomy  in  children,  why  unsuccessful, 
by  Alex.  Thom,  M.B.,  212;  by  li.  W., 
Parker,  410 ;  in  tubercular  laryngitis,  383 ; 
without  the  cannula,  385 ;  in  morpliine 
poisoning,  385  ;  a  question  regarding,  965. 

Tripiek,  Prof.  R.,  la  fibvre  typhoide  traitde 
par  les  bains  froids,  rev.,  650. 

Triple  qualification,  182,  485. 

Triturates,  tabloid,  390. 

Tropical  diarrhoea,  chronic,  by  Sir  J.  Fayrer, 
205. 

Troup,  Francis,  M.D.,  the  diagnosis  of 
early  phthisis  by  the  microscope,  1 ; 
medical  periscope  by,  278,  374,  479,  562, 
954,  1151. 

Tubercle,  the  influence  of  certain  medicinal 
agents  on  the  bacillus  of,  in  man,  by  G.  H. 
Mackenzie,  M.D.,  596. 

Tuberculosis,  occasional  periscope  of,  by 
R.  W.  Philip,  M.D.,  179;  the  relation 
of  surrounding  conditions  to  the  progress 
of  bacillary  invasion  in,  180;  predisposi- 
tion in,  181 ;  communication  of,  by  ritual 
circumcision,  182;  notes  on  report  of  de- 
partmental committee  appointed  to  inquire 
into  pleuro-pneumonia  and,  in  the  United 
Kingdom,  by  Dr  Peel  Ritchie,  617,  693; 
inoculated,  765 ;  transmissibility  of,  954  ; 
papillomatosa  cutis,  1155. 

Tucker,  G.  A.,  lunacy  in  many  lands,  rev., 
155. 

Tuke,  Drs  J.  Batty,  and  G.  Sims  Wood- 
head,  reports  from  the  laboratory  of  the 
Royal  Gollege  of  Physicians,  rev.,  1127. 

Tumours,  the  etiology  of,  by  G.  Sims 
Woodhead,  M.D.,  26. 

Turner,  Prof.  Sir  William,  the  physician 
a  naturalist,  193. 

TuRTON,  Surgeon-major  F.  A.,  obituary 
notice,  1163. 

Typhoid  fever,  alcoholic  remedies  in,  93 ;  in 
children,  281;  surgical  treatment  of  the 
abdominal  complications  of,  387  ;  vaccina- 
tion against,  573 ;  in  infancy,  672. 

U 
Undekhill,  Charles  E.,  M.D.,  introduc- 
tory address  to  the  Edinburgh  Obstetrical 


1176 


INDEX. 


[1888-1889. 


Society,  512 ;  occasional  periscope  of  the 
diseases  of  children,  281,  672,  1065. 

University  of  Edinburgh,  286,  287,  1069. 

Unofficial  formulary,  B.P.C.,  rev.,  161. 

Ureters,  palpation  of  the,  in  the  female, 
564. 

Urethan,  74. 

Urethra,  congenital  stricture  of,  as  a  cause 
of  incontinence,  1068. 

Urethral  stricture,  curability  of,  by  elec- 
tricity, 855. 

Urethrocele,  cause  and  treatment  of,  564. 

Urinary  organs,  the  surgery  of  the,  386. 

Urine,  the  systematic  examination  of  the, 
for  proteids,  by  D.  Noel  Paton,  522  ;  pig- 
mentary reaction  of,  in  intestinal  diseases. 
954. 

Urticaria,  how  wheals  are  produced  in,  1154. 

Uterus,  a  case  of  rupture  of  the,  by  A.  A. 
Matheson,  M.D.,  713;  extirpation  of  the, 
in  carcinoma,  88,  565 ;  anteflexion  of  the, 
565 ;  spontaneous  rupture  of,  566. 


"  Vaccination  "  article  in  the  Encyclopaedia 
Britannica,  973. 

Vaginal  tampon  in  the  treatment  of  certain 
effects  following  pelvic  inflammation,  85. 

Vanguard,  the,  1888,  rev.,  63. 

Vaparoles,  770. 

Varicose  veins,  the  treatment  of,  83. 

Verruca  plana  of  the  face  in  youth,  1155. 

Vichy  mineral  water,  391. 

ViEROEDT,  Dr  Hermann,  anatomische, 
physiologische,  und  physikalische  daten 
und  tabellen  zum  gebrauche  fur  mediciner, 
rev.,  469. 

Viscera,  notes  of  a  case  of  transposition  of 
the  thoracic  and  abdominal,  by  Harvey 
Littlejohn,  907. 

Vocal  cords,  cases  of  endo-laryngeal  removal 
of  growths  from  the,  by  G.  Hunter  Mac- 
kenzie, M.D.,  36. 


W 

Wallace,  Prof.  Egbert,  India  in  1887, 
rev.,  161. 

Warburg's  tincture  tabloids,  485. 

Wakfvinoe,  Dr  F.  W.,  record  of  practice 
in  the  hospital  of  Sabbetsberg  at  Stock- 
holm, for  1887,  rev.,  735. 

Warts  and  callosities,  treatment  of,  78. 

Watson,  Dr,  Montrose,  obituary  notice, 
1163. 

"  What  must  1  do  to  get  well  ?  and  how  can 
I  keep  so,"  rev..  1132. 

Whitlow,  961. 

Whooping-cough,  narceine  in,  73 :  thyme  in, 
73. 

Williams,  C.  J.  B.  and  C.  T.,  pulmonary 
consumption,  rev.,  461. 

Williams,  AV.  R.,  F.  K.C.S.,the  principles 
of  cancer  and  tumour  formation,  rev.,  638. 

Winckel,  Dr  F.,  diseases  of  women,  rev., 
647. 

WiNDLE,  Prof.  B.  C.  A. ,  a  handbook  of  sur- 
face anatomy  and  landmarks,  rev.,  935. 

Wise,  A.  Tucker,  M.D.,  Alpine  winter  in 
its  medical  aspects,  rev.,  743. 

Wolpenden,  R.  Norris,  M.D.,and  Sidney 
Martin,  M.D.,  studies  in  pathological 
anatomy,  rev.,  641, 

Wood,  Prof.  H.  C!.,  therapeutics,  its  prin- 
ciples and  practice,  rev.,  651. 

WooDHEAD,  G.  Sims,  M.D.,  on  the  etiology 
of  tumours,  26. 

Wylie,  David,  L.E.C.S.E.,Errol,  obituary 
notice,  1162. 

X 

Xeroderma  pigmentosum,  77. 


Year-book  of  treatment  for  1889,  rev.,  940. 

Z 

Zoster,  relapsing  double,  763. 


END   OF  THIRTY-FOURTH  VOLUME. 


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